Chain of custody form for indoor air quality survey at

NYC 9/11 Public Portal Document

I The whoa copy will ba returned with your report. Pisan retain pink copy for your records.

II Gallon Laboratories Request For Industrial Hygiene Analysis Company Name: ~,~,' C/I!GrC • __ 6801 OX369 Hoed _ P.O. Box 369 Site Name: I a 7 V i~ E. Syracuse. NY 57 Project A: Tel: 315 3 X 2888-377-LabA (5227) Sampled By: /.ro u.S Fex~ 315 437-0671

Send Report to: C + A C 11/t'r.t Zt4L Invoice to: 7 v << w 40 , S ',jqe AcII.4d'4.ti' ❑ Purchase order number Exp Date (or) . Card * ❑• Credit Card (type) ❑ Verbal Authorl2ation am OR ❑Rush:Date and Time Requested: I I pm ~darMd nd Time t/ phone « (S/6) — ~76 _ - 8' _ ext. ❑ Phone Results to: Fax # (. ') _57— CO Q3 ❑ Fax Results to:

❑ Email Results to: Air Sample Analysis Method Sample Medium Requested Reference Sample Identification Date Sampled Catel # /Lot # Volume liters

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C I 'For passive monitors please list time exposed in minutes.

Comments (Please list any known Interferences present In sampling area): __rp gnature Datelrime I Chain of Custody I Print Name bb989L591:SL Bb:Oi 1.O.OZ'AON L ` ^""""' `'" C`.t, •• i • .d •C HCI 90d 500 NYC-WTC 000108489