Chain of custody form for indoor air quality survey at

NYC 9111 Public Portal Document

Request For Industrial tiygtene naiysts Galson Laboratories Company Name: p yr o 9801 KlrkvNla Road a P.O. Box 389 Site Name: SO (c E. Syracuse, NY 13057 ..1 Tet'. (315) 437-7252 888-577-Labs (5227) Sampled 8y: CAries gkA Project ' Fax: 315 437-0571

Send Report to: I Z, A Cc.- t' &tti 2VC Invoice to:

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❑ Purchase order number I Card a P Date ❑ Credit Card (type) ' 0 Verbal Authorization am Standard Turn-Around Time OR ❑ Rush: Date and Time Requested: r I pm Q ~/ ext. ' 0 Phone Results to: Phone e (S/6) — 576 QVI — yv LL (7f ❑ Fax Results to: Fax e - - C'9

❑ Email Results to:. Sample Medium Air Sample Analysis Method P Identification Sample Date Sampled P Catalog y / Lot C Volume (liters)' Requested Reference

I it gp o Cñ-t Cad. 360 q0 37ic p 7300 C✓ sov dlo C ofo___ 3 A x~~ rr06 '7 3' ":.ms I `rte of c f I I X01 C ' 1I Slolo -C/h C $ F fors SS' fl 11oJO&C A-le. S~ ; r- ' 11120109 o Eve 00 11i 10 C O? 30 Ill 8 O 1O. CrL it 5Uc /Pi4(I 370 F ,o s 6 • __ ___

IM) .'3" T0I gOf C ' I t 1011-' L 17C B ( f c; .~s o IIkK 6 'A(yd1M '1k97 I ____ __ -. ______ __

For passive monitors please list time exposed In minutes.

comments(Please list any known interferences present In sampling area): r )fltt&) d )f

o n k ! gD D t .,~,I.pt~ •~. I ~l d&( c v n Chain of Custody f Print Name I Signature Date/lime

Relinquished by: ~ ,1/ q it/d WSAi 11f1q/0, l95 Received by LAB. Samples received after 3pm will be conataerea as next aay-s oue,ness. I LOCI S00 I API I-

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NYC-WTC 000108481