DEPARTMENT OF ENVIRONMENTAL PROTECTION
BUREAU OF ENVIRONMENTAL COMPLIANCE
ASBESTOS AND LEAD CONTROL PROGRAM
59-17 JUNCTION BOULEVARD
CORONA, NY 11368
JOEL A. MIELE. SR-P.E.
COMMISSIONER
BULK
ANALYSIS CHAIN OF CUSTODY
Incident No.: Date Sampled:)1
Premise: Boro• ,V
4
Time:
Inspector:
Print Signature
Turnaround Time: Immediate (` 24 Hours I ( 48 Hours I I I Week I
SAMPLE UMBER I I DESCRIPTION LOCATION SAMPLED I LAB ID
1. ~ Io E70 ~' o+M
2. Li
3. Z'L oO (A W1( r 0 c
4. K ems c 2 4
5. Z21 a Otb N
6.
7.
S.
9.
10.
ANALYSIS REQUESTED: Asbestos PLM I I %Asbestos TEM I I Lead I I
Date . ' 'ime Aece ltd Bs Comments
am Print
pm
Sign
2. am Print
pm
Sign
3. am Print
pm
Sign
4. am Print
pm
Sign
5. am Print
pm
Sign
DEP ACLP RE5100
NYC-WTC 000113204
OCR can misread numbers and units. Confirm readings against the page image before using them.
NYC-WTC_000113204Source: NYC Law Department, mirrored locally