NYC 9/11 Public Portal Document
PURTE.. 1. IROK AL
39 W38™ STREET, 12™ FLOOR
NEW YORK, NY
PHONE. 212 768-0516 FAX: 212 768-0759
PROJECT INFORMATION (fill out ALL information)
ASBESTOS BULK SAMPLING AND CHAIN OF CUSTODY FORM Page
2 of 2
CLIENT: PROJ. NAME: ; PROJECT #: DATE:
S/O BROADWAY O0)-090) |. G/ESSC/
CLIENT ADDRESS: PROJ. ADDRESS: ¥ , 7 7
/76 BRabwty NY MY
WORK AREA: Comments:
Turnaround Time: Method of Submittal: INSPECTOR: TS BE 5
STAT 6HRS 18HRS FIELD 7% USMAIL Tepay MANAGER: 3 COX S MAW
24HRS 72HRS OTHER FEDEX OTHER ‘ ‘ 7 oO We a
HA # | Sample ED # Lab ID # Material Description Sample Location Quantity Friability Results
(incl. color) (SF) YIN
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TH live ott Dttsi Sosiclee slpr. JOC Tan
7 _f - i CHAMOTEES
[2 42) Dusr Lrsicle fier. fO'C 22.
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re, CHAIN OF CUSTODY LAB INFORMATION
N Relinquished By (Print/Sign) Date/Time Received By (Printv/Sign) Date/Time ; Analyzed By (Print/Sign) Date/Time
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NYC-WTC_000196104
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NYC-WTC_000196104Source: NYC Law Department, mirrored locally