NYC 9/11 Public Portal Document
• GalSon Request For Industrial Hygiene Analysis
1 Laboratories Company /
6601 Kirkville Road p y Name: C6 / e' %~L c lirCi1 (c t r
P.O. Box 369
E. Syracuse, NY 13057 Site Name: 3J4 & ree S
1 Tel: (315) 437-7252 888-577-Labs (5227) Sampled B Project #:
.,
Fax: 3115 437-0571 y C PS .C
Send Report to: C t7- -\CA C s 1 qN „ *.. .- Invoice to: C4 /J~cn ~ v//4~-Is, s
7 SfP•et' 7/ S nit
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1 D Purchase order number
(or)
❑ Credit Card (type) Card # Exp Date _
1 ❑ Verbal Authorization
Standard Turn-Around Time OR ❑ Rush: Date and Time Requested: / / am
pm
//
Phone # (5) /
1 ❑ Phone Results to: — t — g g Y5 ext•
❑ Fax Results to: Fax # (57) -• -76-bo93
❑ Email Results to:
Sample Medium Air Sample Analysis Method
1 Sample Identification Date Sampled Catalog # / Lot # Volume (liters)* Requested Reference
►Igo / sb ,g /o bush- __ VI Y- So0
• 1 1 0 1 lb 37//7c Io.8 300
1 go s v'C /P 'ho 37 P i.oX . ss 6
l I1 o g 2 V G t 3a~,c s fl 1,Cit1 To/c.
I - t 190►1 i3v i57''- F fors cso -
(I go 20 f /1S dr&r 6
I
1 __ ___ ______ __ -
1 ____ __ ___ ______ __
-
1
-For passive monitors please list time exposed in minutes.
Comments (Please list any known interferences present in sampling area):
Chain of Custody Print Name Signature Dale/ Time
Relinquished by: Sf %. ' /, ` , q4' / •",'
fli .
1 Received by LAB. '-171•
Samples received after 3pm will be considered as next day's business.
LAB ORIGINAL
10:00
NYC-WTC 000108484
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