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�.L tl• ti_ ti♦ f♦ f♦ 1♦ ta, ti•raN�aU L <br /> OVIRONMENTAL REQUEST F4R BORATORY Prolect No �)(i12�>, <br /> CONSULTANTS ANALYTICAL SERVICES Batch No 4 12,, c� <br /> Ind Code p <br /> Date Logged In By <br /> �O Name r r Title Purchase Order No Client Job a <br /> r� Pit Com an Dept w Name <br /> L Mailin Address Z 1/ v Company <br /> Cit State, Zi -ate r De <br /> N - u) z Address pt <br /> Telephone No Telelax No City. State, Zi C <br /> Date Results Req Rush Charges Authorized? Phone/Fax Results Samples are ANALYST REQUESTED <br /> T ❑Yes ❑ No ❑ ❑ (check if applicable) c (Enter an'X'in the box below to indicate request,Enter a'P'if Preservative a <br /> Special Instructions (method, hrrid a1 detection. etc) O Drinking Water 1° <br /> Sf J)h Y -rA— I+�X <br /> e ❑ Collected in the <br /> ' Explanation of Preservative S trA ors & � TC\t- 8 <br /> k[� ? State of New York <br /> CLIENT SAMPLE IDENTIFICATION DATE MATRIX/ AIR VOLUME E <br /> SA PED MEDIA (specify units z' /�� /`` FOR L <br /> 6 L1� w be USE 0 <br /> 1 <br /> _ r <br /> rE p S7. <br /> +n <br /> Z <br /> Collected by A- s��r (print) Collector's Signature <br /> CHAIN Relinquished by Datelrime 1Z-11t—FAV + <br /> OF �^ to Received by DateR ime <br /> CUSTODY Relinquished by Date/Time Received at Lab by Date/Time <br /> Ad <br /> Method of Shipment Sample Condition Upon Race CA Acceptable [3 Other (ex ai <br /> Authorized by Date Flr_ <br /> (Client Signature Must Accompany Request) <br /> Please return com Ieted form and sam les to one of the Clayton Environmental Consultants, Inc labs listed below <br /> 22345 Roelhel Drive Raritan Center 400 Chastain Center Blvd, N W 1252 Quarry Lane DISTRIBUTION <br /> Novi, MI 48375 160 Fieldcrest Ave Suite 490 I loasanlon, CA 94566 Wl0TE - Clayton Lebon <br /> (010) 344-1770 Edison, NJ 00637 Kannesaw, GA 30144 (510) 426 265/ Yt:l I OW Clayton Accour <br /> (908) 225 6040 (404) 499 7500 <br /> W92 PINK Client Retains <br />