NYC-WTC_000206871

NYC 9/11 Public Portal Document

Veritech, 175 Route 46 West, Fairfictd, NJ 07004 PHONE (800) 426-9992 A Division of HAMPTON-CLARKE, INC. NJDEPE # 14622 CHAIN OF CUSTODY RECORD FAX (973) 439-1458

CUSTOMER INFORMATION REPORT INFORMATION PROJECT INFORMATION CUSTOMER: SEND REPORT TO: TURNAROUND DELIVERABLES ADDRESS:___ (CONFIRM RUSH TAT’S WITH LAB) (PLEASE CHECK BOX) TELEPHONE: □ STARDARD FAX:____________ □ STANDARD □ full □ RUSH □ WASTE □ BUST PROJECT: PROJECT MANAGER: □ 24 HOURS 100% □ NJ REDUCED □ EXCEL SEND INVOICE TO: □ 48 HOURS 75% □ HAZSITE □ CUSTOM PROJECT LOCATION: STATE: □ 72 HOURS 50% □ ELECTRONIC DELIVERABLE □ 1 WEEK 25% PO NUMBER:___ □ OTHER (SPECIFY) □ TODAYS 10%

ANALYTICAL REQUESTS LAB Q (3 No. of Bottles SAMPLE UJ LU

SAMPLE IDENTIFICATION METHANOL G UJ C3 s§ ANALYSIS NUMBER BOnLE # luG Ld LU _J 2^ CQ o (LAB USE ONLY) 2S s

Q

K SAMPLER CERTIFIES THAT EACH SAMPLE RECEIVED PROPER FIELD PRESERVATION (IF REQUIRED) (INITIALS) I SAMPLE HAZARDS: FLAMMABLE | | SKIN IRRITANT || NON-HAZARD || UNKNOWN I I NOXIOUS FUMES □ R SPECIAL o TEMPERATURE UPON RECEIPT: o INSTRUCTIONS: I RELINQUISHED BY: DATE/TIME RECEIVED BY: DATE/TIME o o co o AGENT OF: 1 AGENT OF: I___ RELINQUISHED BY: DATE/TIME RECEIVED BY: DATE/TIME to co to AGENT OF: ! AGENT OF: I O',

NYC-WTC_000206872