Chain of custody form for indoor air quality survey at

NYC 9/11 Public Portal Document

report. Please retain pink copy for your records. I The white copy will be returned with your

Gallo n Request For Industrial Hygiene Analys'i's ' Labors IIS Company Name: (A 4c o _

8001 KlrkvIlk Rood Road P.O. sax 3e0 81te Name: 1 SC?f . //#t.' 51~~~° ~' ' ' E. Syracuse. NY 13057 -Labs (62271 ProJoat A: Tel: (316 437-7252 988-677 Sampled 13y. ,s Fax: 5 437-05771 311 } / /~ invoice to: Sertd Report to: ~l7 • Jt ~' ~r ~" —

1/!. /1'fa

1 ❑ Purchase order number (or) Card 0 Exp Date 0 Credit Card (type) ❑ Verbal Authorization OR ❑Rush: Date and Time Requested: / I am Standard Turn-Around Time L Q► p► Y pm JT7 6 _ O Ol y ext. Phone # L6 ❑ Phone Results to: Fax M is ~W -376- c >93 p

❑ Fax Results to:

' ❑ Email Results to: Method Sample Medium Air Sample Analysis Requested Reference Sam{eIdentlficatlon p Date Sampled Catal 1/ Lot M Volume lllers ' j V~ 26o 0oST t IgoI 37f110E1 O1 S Lea 2 , 3Co It_Io1 o T ti/silo 7fEioJxA RO (/ /P//4 . CSC i tiiôlo TM u!ig/ot 1 ►to t o 111110( 'nd; C,t-iv' o E 110 C. /S— PC S5'03 Ilig TM 1t//s4, ;s' ,4le 'c ui' YD 57/11 Th/b 1 Ir t'4C O I $O /,:/o ?V L O- D S M a /~k!% 0. Le"td 73o 8010 O S50~o 1( 110( o _Tt1 l Iis/oL 7P(E / u )it,1,CM) _ " VoC T0/ H(W(_t_sr I t IIv Pc i7tei'ctry 55p3' cc U_tq0111 t Fi r l I ____________ ( ► 0l 37 FO Ge/ 1] A SS0 t7coo i3 _ HI/s ?VC.... e. w /V J 111, / SIo l r1 t•`l

aLd&K I Gff /.r` I 1(11)k') minutes. For passive monitors please list time exposed in sampling area): Comments (Please list any known interferenoes present in A ;~sii.a _/ ,,/,,,/z,, /D.-OD S. k,~~•

- . Si nature I Oateltlme

II Ct ain of Custody

SOd 500 r1....i. Print Name H3I2i •b •C bb889LS9tSL Lb:Ot tto.0Z •AON

NYC-WTC 000108487