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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r
SkaC.
~Pw
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. ?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
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£0d 500 H3I21
NYC-WTC 000108477
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