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:
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❑ 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
M II loo uS $ VC'i D o
1 $ 00
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'For passive monitors please list time exposed in minutes.
Comments (Please list any known Interferences present In sampling
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Chain of Custody I Print Name
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NYC-WTC 000108489
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