Chain of custody form for indoor air quality survey at

NYC 9/11 Public Portal Document

I The white copy will be returned with your report. Pleasa retain pink copy for your records.

Gal Son Request For Industrial Hygiene Analysis ' Laboratories Company Name: / r' 6601 Ktrkville Aoad P.O. Box 369 Site Name: +t • _ . E. Syracuse, NY 13057 (5227) T. 316) 437.7252 886-577-Labe Sampled By: #: Fax: 316 437-0671 v Invoice o: Send Report to: • Apo ~~yyff J ftVe !•'~~iNO~ICi

I ❑ Purchase order number (or) Card ie Exp Date 0 Credit Card (type) I ❑ Verbal Authorization Standard Turn-Around Time OR ❑Rush: Date and Time Requested: ._ I / am pm t~ r ext. ' Phone 6 i /6') — S76 — g! 0 Reults to: Phone s ~J Fax 8 (Z 4) — ?6 — nT ❑ Fax Results to:

❑ Email Results to: Sample Medium Air Sample ' Analysis Requested Method Reference Sample Identification Date Sampled Ceta' e / Lot It Volume titers • SSo (ç( / f/( & cil%siL 5V, PC8 ' // 4 Ol // f /e/ :s; `0 - /i l o a, Goo • ~.~ tr rS/o/ 'ei '

I ______________ ______

(1 Q', ttZl~ of 'For passive monitors please list time exposed in minutes.

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

I as ~ a.'ao t3 Dale/Time Chain of Custody Print Name • I II I w 2l d'C bt999LS9LSt Sb:Ot IO .OZ AON, ZOd ,0~

NYC-WTC 000108478