Chain of custody form for indoor air quality survey at

NYC 9/11 Public Portal Document

for your records. The white copy will be returned with your sport. Please retain pink copy

Galson Request For Industrial Hygiene Analysis • Laboratories Company Name: 6601 Kl Road P.O. Box 369 Site Name: F. Syracuse. NY 13067 Tel: (316) 437.7252 686-5T7-Labs (6227) gampled 6y: j ro)oot N: Fax: 315 437.0671

r Send Report to:

____________________

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SkaC. ~Pw h L . ?C. Invoice to:

/i/1/ - ❑ Purchase rder number Card # Exp Date ❑ Credit Card (type) ❑ Verbal Authorization tandard Turn-Around Time OR ❑Rush:Date and Time Requested: r I am pm X ext. ❑ Phone Results to: . Phone # (S/") — S76 —

Fax # (J7) — 376 — d0 Q ❑ Fax Results to:

❑ Email Results to: Sample Medium Air Sample Analysis Method Sample Identification Date Sampled Catalog # / Lot # Volume (liters) Requested Reference

G / Bo 37Pl E / Xi4D 3p Svc c. #A,1 S Sc 'iispii o/ 1/a .3 7. Zci 05 00 /P 2. Gt4J 73vd M t: - 0500 /dv R to 37P6qr4L 378 "b/°' o0 o o cgs 3G 4 o/ o SO oo o 17 er, 14 37 4 Ji-vc P.4ii 550 If1101f A !~ r8 3?m 3C C' Gt'I 73 0 0 350 0 I. I / Cif G ' c y oo9 I'd( /64t r a GF isr ~S. 5503 7 37Mi i7 1? ¢ G '3 o I 01 1ZA If/01 Z. III 0I I 4 fi'/ff/oi _______ ________ ______

For passive monitors please list time Ixpoeed In minutes.

Comments (Please list any known Interferences present in sampling area):

I /I/oo o, .c -"-

&gnaturB Datamme Chain of Custody f Print Name •V •3------ - - — b b989LS9LSL y v:u< LV. UG L . 1%U4 .. £0d 500 H3I21

NYC-WTC 000108477