NYC-WTC_000202421

NYC 9/11 Public Portal Document

AIK SAMFblPNLr P5U work order # . RSC to 4418 Pottsville Pike phone: (610) 921-8833 CHAIN OF CUSTODY Page Reading, PA 19605 fax: (610) 92i -9667 PO # Quote # IName

Report Name Company /h/'C fU/ ■ ■ Submit Company Hailing Address Results Mailing Address ~J~O2A jL ■- Invoice pity State ZIP to to To: City_____________________ state ZIP f\j V To: |Telephone K Fax# tn Telaphone# ’‘Z I Z' |Credil Card Into (include exp, dale) I

dj Job/Project Name: 9 tn COMMON MATRIX TYPES I o 1, Badge (OVM/Passive Monitor) 6. Wipe (specify type) Sampler's NaiTie(s): co 2. Tube (specify type: charcoal, silica, XAD, etc) 7. Tedlar Bag Sampling Location (Specify State); 3, Train (filter + lube, 2 lubes in series, etc) 8.Summa Can Due Date (Rush results requires Lab approval): 4. Filler/Casselle (specify PVC, MCE, GFF, etc.) 9. PUy/Resin/XAD REPORTING REQUIREMENTS (Circle all that apply); 5. Impinger Solutions (specify components) 10. Other (list details); Full Data Package Reduced Deliverables Pkg Electronic Data Deliverables

FINAL AIR * MATRIX MEDIA SAMPLE FLOW RATES SAMPLE DESCRIPTION VOLUME,, SAMPLE ANALYSIS REQUESTED I (ID must match container labels) (see above list) (list catalog (specify; Oei^' DATE number) minutesret^ TIMES (specify units: Start Slop Initial Final Average Use iittm-hnieiits if ueceswry. I’lease specify iiiellioci letiiiireiiieHls. 1 rij d'YD ■yy /V/g’A.y 6^^^ 2 f20 £>• 3 7, 01 ! 4 A/ A/ — ' I

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(5 OJ 9 n in 10 □ N>; (2) Received by: (1) Relinquished by: Date I , , Time Date Time -^/■€m2zLvi / Tj L I □ i! (3) Relinquished by: Date Time (4) Received by: Date I c m rXOUL n Method of Delivery: UPS FED-E PSC Courier Client US Mail Other ISi! NYC-WTC_000202421