NYC 9/11 Public Portal Document
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your records.
report. Please retain pink copy for
, The white copy will be returned with your
Analysis
1 12 Gatso11 Request For Industrial Hygiene
LabOratOrle9 Company Name: ~ ,' {~z ~✓
6601. 3llls Rood
I P.O. Box es
P.O
E. Is racuee, NY 13067 -677-Labe (5227)
Tel. (315 437-7262
Fax: 316 437-0671
698
Site Name:
Sampled By' /zr
rAJACt 1f:
Invoice to:
RCA
I Send Report to: ji
S
O
M ,.
❑ purchaseororder number Exp Date
) Card #
❑ Credit Card (type)
❑ Verbal Authorization am
❑Rush: Date and lime Requested: gg pm
Standard Turn-Around Time OR
Phone 1t S~6 —
It~1 T ext.
❑ Phone Results to:
- Fax • (/6 X76 — COQ
0 Fax Resutts to:
0 Email Results to:
Analysis Method
Swnpte Medium Air Sample Requested Reference
Sample Identification Date Sampled Catal II Lot # Volume liters '
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minutes.
•For passive monitors please list time exposed in
present In sampling area):
Comments (Please list any known interferences
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I Chain of Custody - Print Name
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HCI21
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NYC-WTC 000108485
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