Chain of custody form for indoor air quality survey at

NYC 9/11 Public Portal Document

Galson Request For Industrial Hygiene Analysis I • Laboratories 6601 Kirkville Road P.O. Box 369 E. Syracuse, NY 13057 Comp Name:

Site Name: I C6 SohILI i IL ttG C o rc/ Ca r

-0571 888-577-Labs (5227) Tel: (315) 437-7252 Fax: 315 437 Sampled By: CX(ai-( RI cti Project #: I Send Report to: C 14 1Z.ACOA i /faA.* . 27VC, Invoice to: v Sfircc7' PJauv j,ew ,,vy I ~/' S7r /Qfi~.O ~

❑ Purchase order number I (or) ❑ Credit Card (type) Card # Exp Date

❑ Verbal Authorization Standard Turn-Around Time OR ❑ Rush: Date and Time Requested: i i am pm 0 Phone Results to: Phone # (S/6) — 576 -6g /~ ext• • ❑ Fax Results to: Fax # (5l4 - 3_76 - C~93 ❑ Email Results to: I Sample Medium Air Sample Analysis Method Sample Identification Date Sampled Catalog # / Lot # Volume (liters)* Requested Reference

I goofCi1R 1I 18oI v - qo C, so0 l go1o2CA Cead- 60 7c p 7oo I 1 go103CA-f, P f} 360 37P77 ss06 of sT Ill '0lo C 7A0 31 / IA III VolO L 4f$ 1= S'S'o ,.. j 1'0)06(A Ct~ 5O co?

l l $0108 c Z 3c UCi oo _ • 11110109C 36 7300 1 8o io cik if 70 'r rr - h ssV6 • it 1g cal( C R. CAIII To s I1 4oI l aL (~ 7c 13 &-F /oc Ys03 it 0 113 UR, /krc vr 0 r t&v C97 j

I -. _____________ ____________ _____________ __________

•For passive monitors please list time exposed in minutes.

mments (Please list any known interferences present in sampling area)'.. -

I S c 1fr/ie& v am. - S A-0 ,o% I11gDIoYcRP w0.s zero fs rl-

Chain of Custody Print Name I Signature i" Relinquished by: I 37 A'/4/4. t.vS/q c Received by LAB. V Samples received after 3pm will be considered as next day's business. LAB ORIGINAL NYC-WTC 000108482