Chain of custody form, Environmental Testing Laboratories Inc

NYC 9/11 Public Portal Document

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ETL CHAIN OF CUSTODY DOCUMENT OD

OD O Environmental Testing Laboratories, Inc. O I 208 Route ]09 • Farmingdale • New York 11735 o

631-249-1456 • Fax: 631-249-8344 N 01695 o

s Project Name: Project Manager: ’ Sampler (Signature): (Print): CM

Project Address: T. '"T' H

O y I Rush by , IN lc 2. QAmiPI P IWPn Type; SS = Split Spoon; G = Grab; C = Composite: B = Blank *Air - Vol. (Liters) OMrVirUC imru L = Liquid; S = Soil; SL = Sludge; A‘ = Atr; W = Wpo include: Flow (CFM) ID Date Time Type Matrix Sample Location Total. # Cont. 1 T -''

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14 '-i - t- £ Relinquished by (Signature): Date Printed Name & Agent: V

Received by (Signature): Date Printed Name & Agent t Time Time Relinquished by (Signature): Date Printed Name & Agent: Received (or Lab by (Signature): Date Printed Name Time Time : Comments & Special Instructions QA/QC Type: Number & Type of Containers: Preservatives: Temp: ft ' r -- . - (t.r 4.' .

NYC-WTC_000186428