Chain of custody form for indoor air quality survey at

NYC 9/11 Public Portal Document

Galson Request For Industrial Hygiene Analysis Laboratories / L 6601 Kirkvitle Road Company Name: C6 ~ C/~ , " E. Syracuse, NY 13057 Site Name: 2-/v' /50 styee Tel: (315) 437-7252 888-577-Labs (5227) Sampled By: AC~~~~,' 1li Fax: 311/5 4337-0571 1 Project #: [[ 1 .) Send Report to: 4114 ,E' cA c sc/ J Invoice to: v ea % /t4 ' i i Qo 3 s f y e /4 r +.o ~/c .

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

❑ Verbal Authorization

Standard Turn-Around Time OR ❑Rush: Date and Time Requested: / / am pm ❑ Phone Results to: Phone # cS/h - X76 - YV5" ext. • ❑ Fax Results to: Fax # (s/~ - s76- C 43 ❑ Email Results to:

Sampled Sample Medium Air Sample Analysis Method Sample Identification Date Catalog # / Lot # Volume (liters)' Requested Reference

I o o1_ It/IS/O VL us/- tI iotoP-5Ti'i1 t r ig 0 37 CEP o,S _ Lea 7 300 • g 3 T - (l(s/0 37PIf5v i 3O St/c./P//4 _SUS Mto _ 11 f8 0(` :: ,w, cti'/ 2 V O`C' - /S-71 i t180a~ iM (r//8ai~ For;s, :G[6 Pc 1 sso3. • ■ 1I I I O STi~1 ~~ l~~/o ■ igo S rM ~t VG Tb o ( 180!0 9 S M o / 22; p LPQ • ( Iol 10 3Tt4 I o 37& J O SV S50(,

1 ii oi i s (//Sloe C-Ff or;5t co l3 S lc 8 F, r Ply t, . (f/i8/o1 3~~rf~ r.t/~r,¢~ : t • 3 Voc/PA-f4 5sa 31 aNK f(l s /o V C~ •1'r vs_ p~'oo B(aN ►t(r81a( ; I file P 'M cc,v ~, ~c%$log PC Ssd3 'For passive monitors please list time exposed in minutes.

Comments (Please list any known interferences present in sampling area):

Chain of Custody Print Name I Signature Date/Time

Relinquished by: S't ri'eti4/%>_ t' ~ C~ (g. Y . Received by LAB. (Y1 , KtV /1/JO/c'! ■ Samples received after 3pm will be considered as next day's business. LAB ORIGINAL NYC-WTC 000108488