Chain of custody form for indoor air quality survey at

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 /R/~•yew / fV: 1 iNJitu✓. A' I t0) S rve_ /Yl r /;Aw 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