NYC-WTC_000202775

NYC 9/11 Public Portal Document

Verltech, 175 Route 46 West, FalrfleM, NJ 07004 PHONE (800) 426-9992 A Division of WWPTQN-CLARKE, MC. NJOEPE # 14622 CHAIN OF CUSTODY RECORD FAX (973) 439-1458

CUSTOMER INFORMATION REPORT INFORMATION PROJECT INFORMATION CUSTOMER: pA ■ M T VT SEND REPORT TO: . Pl^-W n AO I wi^u (ntASt CHECK BOX) ADDRESS: (OmriM WISH TAPS WITH IAB) CafSTAMtARO □ FUtZCMMI TELCmmE: U STANDARD □ WASTE □MKT FAX: __ ^RUSH IQ NJ REDUCED □ CAT-A PROJECT: ......Ajit.O.... .................... E(JCTR(»«C DEL IVERABLES PROJECT MANAGER: iA24H0URSI«)% (PLEASE CtKCKBGX} PROJECT LOCATION: SEND INVOICE TO: p fl - W -j J 48 HOURS 75% JMAZSITE/CSV □ EXtEl-HJCC STATE; □ 72 HOURS 50% □ EOU IS □ EXCEL-NV TAG W PO NUMBER: □ 1 WEEK 25% □ OTBOM JEXCELPAACTIt □ 10DAY5 10% JOTHEBtSfECiPO

ANALYTICAL REQUESTS LAD SAMPLE s o LJ325L No. of Bottles METHANOL c 6 IS NUMBER SAMPLE IDENTIFICATION 11 ANALYSIS (LAB USE OHLY) BOTTLE# si wS 1- V Si H P// j

o H I J I I I K SAMPLER CERTIFIES THAT EACH SAMPLE RECEIVED PROPER FIELD PRESERVATION (IF REQUIRED) tlNITIALSTl I SAMPLE HAZARDS : FLAMMABLE Q N0N-HA2AR0 Qj UNKNOWN Q NOXIOUS FUMES Q SION IRRITANT s o o r^^^lONS: ]A TEMPERTUREUPON RECEIPT: o I RaiNQUISHED BY; QATE/TIME RECEIVED BY: DATE/TIME o o AGENT OF: /' C/ " . ........ / AGBITOF: LaJ o REUNQOISHEO BY: ' DATE/TIME RECEIVED BY: DATE/TIME cn on on AGENT OF: .1 AGENT OF:

NYC-WTC_000202775