NYC-WTC_000202539

NYC 9/11 Public Portal Document

AIR SAMPLING PSC Work Order #

N 4418 Pottsville Pike phone: (610) 921-8833 CHAIN OF CUSTODY Page 151 O. Reading, PA 19605 fax: (610) 921-9667 PO#___________________ Quote# ________ ________ __ Name Name ____________________ _ ICompany Report Submit Company ______________ _______________ __ [Mailing Address Results Mailing Address A A-_________ ______________ Invoice pity "'7 / / ‘state > ZIP CD CD To: Pty /JM ' sLe Jvjsl ZIP _ To: fTelephone # Fax# tn [Crsdit Card Info (include exp, date) I

w m COMMON MATRIX TYPES Job/Project Name: V'-Si> /A_______________ I □ 1. Badge (OVM/Passive Monitor) 6. Wipe (specify type) Sampler's Name(s): 'f CD 2. Tube (specify type: charcoal, silica, XAD, etc) 7. TedlarBag Sampling Location (Specify State): RJ ' 3. Train (filter + tube, 2 tubes in series, etc) 8,Summa Can Due Date (Rush results requires Lab approval): * 4. Filter/Cassette (specify PVC, MCE, OFF, etc.) 9. PUF/Resin/XAD REPORTING REQUIREMENTS (Circle all that apply): 5. Impinger Solutiont! (specify components) 10. Other (list detail.*.): Full Data Package Reduced Deliverables Pkg Electronic Data Deliverables

FINAL AIR MATRIX MEDIA SAMPLE FLOW RATES SAMPLE DESCRIPTION VOLUME SAMPLE REQUESTED I (ID must match container labels) (see above list) (list catalog (specify: ((Jt^s; DATE number) minutes, etc) TIMES (specify units: Start Stop ) Initial Final Average Use altachmenis ifnecessary. Please specify method reguiremenls. 1 VSMM- •S)) Pvc ~i~T ~|iz MifEj 2 ^<1 - eft 19 ~ Mt|i» - S ,2 3=12. _l£ />/ h?- 3 Am -CAto.-1311 ftl-SS u 4 fPr .-rPtVDk- \F co 5 0. « 7 H 8 oi: 1-1 9 I a I i tn It It)

I § w o a (1) Relinquished by: A— Cate^ i Time (2) Received by; Date Time

I w (3) Relinquished by; Date Time ,(4) Received by; Date I Time Q. OJ tn Method of Delivery; UPS FED-EX> PSC Courier Client US Mail other

NYC-WTC_000202539