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:
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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: ._
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pm
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' Phone 6 i /6') — S76 — g!
0 Reults to:
Phone s
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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
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'For passive monitors please list time exposed in minutes.
Comments (Please list any known Interferences present In sampling area):
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t3 Dale/Time
Chain of Custody Print Name
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NYC-WTC 000108478
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