Chain of custody form for indoor air quality survey at

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