NYC-WTC_000206873

NYC 9/11 Public Portal Document

F□ Veritcch, 175 Route 46 West, Fairfield. 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: ihCvVectY _________ SEND REPORT TO: TURNAROUND DELIVERABLES ADDRESS.____________________________________ (CONFIRM RUSH TAT'S WITH LAB) (PLEASE CHECK BOX) TELEPHONE; ________________________________ ^TARDARD ^TANDARD □ full FAX:_____ __ PROJECT: V/Yii V'^oure Ym. \a □ RUSH □ WASTE □ bust PROJECT MANAGER: ' □ 24 HOURS 100% □ NJ REDUCED □ EXCEL PROJECT LOCATION:___________________________ SEND INVOICE TO: Oen'kcU □ 48 HOURS 75% □ HAZSITE □ CUSTOM STATE:___ _________________ _________ □ 72 HOURS 50% □ ELECTRONIC DELIVERABLE PO NUMBER:_____________________________ □ 1 WEEK 25% □ 10 DAYS 10% □ OTHER (SPECIFY)

ANALYTICAL REQUESTS SAMPLE LAB o o TYPE No. of Bottles SAMPLE METHANOL u s /W SAMPLE IDENTIFICATION LU

ANALYSIS Affii/i NUMBER LU LU BOTTLE # LU UiJ —J C/3 II (LAB USE ONLY) ss s cc

0 1

o H

SAMPLER CERTIFIES THAT EACH SAMPLE RECEIVED PROPER FIELD PRESERVATION (IF REQUIRED) (INITIALS) S o SAMPLE HAZARDS : FLAMMABLE Q SKIN IRRITANT | | NON-HAZARD Q UNKNO^^Q^2^ \ NOXIOUS FUMES Qj ---- ---------------------------------- t=J-------------------- o SPECIAL i i TEmkEKAIUKE upon RECEIPT: o I iNSiRuCliONb: o o RELINQUISHED BY: DATE/TIME RECEIVED BY: , DATE/TIME co o AGENT OF:_________ 7^21 AGENT OF: RELINQUISHED BY: ' date/TIME RECEIVED BY: DATE/TIME CO AGENT OF: I AGENT OF: I

NYC-WTC_000206873