NYC 9/11 Public Portal Document
GalSon Request For Industrial Hygiene Analysis
' Laboratories Company Name:
6601 Kirkville Road
• P.O. Box 369
E. Syracuse, NY 13057 Site Name: o ,?
' ~~ Tel: (315) 437.7252 888-577-Labs (5227) ect #:
Fax: 315 437-0571 Sampled By: i 6
Send Report to: C .JNC, Invoice o:
Sto e /l,tiu-a,,
❑ Purchase order number
I (or)
❑ Credit Card (type) Card # Exp Date
❑ Verbal Authorization
Standard Turn-Around Time OR ❑Rush: Date and Time Requested: / / am
c— pm
Phone # (S/1 ) — J -7/
/ p — 99Y7' ext.
❑ Phone Results to:
❑ Fax Results to: Fax # (S/) . -s'76 - Qo ? 3
❑ Email Results to:
Sample Medium Air Sample Analysis Method
Sample Identification Date Sampled Catalog # / Lot # Volume liters ' Requested Reference
I li x'01ao r ,' PC5 sso
/i tSo 7 ;.t k27 G ~o /S
u r / of 5,? .boo
! OI /F~-Fl i: 'f G - SSo
~s G f ~ of /i4 53 1Ycy o0
' / 7 G / o` GFF~ /o,r`sr '53 sso
/(i i 1 svtx o SSo
' Vc %
/ercci r• fop
1 a! GF SSo3
~/ o/ 37nco, Cea Z3'oO
1 0t 1}Ca
~1 l
t/ve 2 rn " 'p e4"; A
9-6 1s
For passive monitors please list time exposed in minutes.
Comments (Please list any known interferences present in sampling area):
Chain of Custody Print Name
f Date/Time
Relinquished by: ~ 1-~ Z I t4 it
. Received by LAB. tfl . c 4.%. Sa D /D;
0 Samples received after 3pm will be considered as next day's business.
LAB ORIGINAL .
NYC-WTC 000108480
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