NYC-WTC_000203535

NYC 9/11 Public Portal Document

AIR SAMPLING PSC Work Order # Wp 4418 Pottsville Pike phone: (610) 921 -8833 CHAIN OF CUSTODY Page I ol / I' ! Reading, PA 19605 fax; (610) 921-9667 ||PO# ~ ________ Quote#___________ Name ( Report Name ^6^7 Submit Company 7^^ t Company Mailing Address Results Mailing Address Invoice J/- City Slate ZIP To: puy AV State /\f‘^ To: Telephone # Faxlf c

[Telephone# — ys.£>£ __________ C/edit Card Info (include exp data) J: c COMMON MATRIX TYPES Job/Pfoject Name: /__________ c

I. Badge (OVM/passive Monitor) 5 Wipe (specify type) Sampler's Namejs):______ _________________________________ 2 Tube ispecify type, charcoal, silica, XAD, etc) 7 TedlarBag Sampling Location (Specify State):_____________________________ 3. Train (filter -t- lube, 2 tubes in senes, etc) S.SuiniQa Can Due Date (Rush results requires Lab approval); 4. Pilter/Cassette (specify PVC. MCE, GFF, etc ) 9. PUFTResm/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 E (see above (list catalog (specify(;^3, DATE TIMES I (specify units. _____ )_ Use atlacfiments ifnecessary. ?! r (ID must match container labels)] list) number) minutes, etc) Start Stop Initial Final Average Please specify metfiod reifuireinenls. ?r 1 ____ 2 3 4 5 5 d 7

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S 2 o r ’ Da’® / I- "Tinis 1(2) Received by

1(4) Received by Date lime I (3) Relinquished by [Date Time Dale / , Time o; E»

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(JI Method of Delivery: UPS FED- PSC Courier Client US Mail nthcir (jO

NYC-WTC_000203535