NYC-WTC_000224775

NYC 9/11 Public Portal Document

I th; J t. ...1 I.-.; 3 F^ceAnalyticar The Chaln-off-CusSmlif Is a LEGAL DOCUBHEMT. All nslsvsint flelsls must be completed Bccurstely. caa.pasotau3.eora

Required Client Inlormation: SSSfiOSH A Required Cllani Inlomialion:_____ SESRion IB Report To: \ Pag®: [ of J I 625144 To Be Completed by Paca Analytical and Client SSCliiOtn C ________ „ \ Ok Wa2z> V-O A tA Copy To: Quote Reference: ATC ru/gfc Kc- Client Information (Chech quote/contract): Invoice To; Requested Dus Dele: TAT; Project Manager:

• Turn around times leas than 14 days subject to

PfOlectName: laboratory and contractual obUgations end may result tn a Rush Turnaround Surcharge. Profile 0: //75^0gg' Turn Around Time (TAT) in calendar days. Phone Rcquootod Anolyolo:

M Section D Required Client Intormalion: Valid Matrix Codes - ------------ PresisrvBlIveis matrix CODE 8 Q

WATER WT UJ o [y <5 SAMPLE OD i2 SOIL OIL SL OL 8 1 o WIPE WP 8 Hmifh X One character per box. AR

I AIR UJ (A-Z. 0-9 /.-) TISSUE TS Sample IDs MUST BE UNIQUE Qltlgfl. OT mm/dd/yy 1,04^ Remarks / Lab IC

1

ABBBBBBBBBBB^BMBroBBMIIMlHiilllWtfBlL..^___ ^gBBagBgBgigiBBMiWBMMHHHIHMaB.aBWBH zBBBI|Bb|I|||I||i MMtiils nmiias lamiHiBBairoBg ESISIS iliMB iiBBBBBiBHBlBlBBBlBfeB^ Q bbbbbbbBb^bbbmbsb^br BSIISIIIliiSliSi^* AIRBILL NO. SHIPPING DATE NO OF COOLERS I,RELINOUISHED BY/AFFILIATION DATE TIME ACCEPTED BV / AFFILIATION DATE ] TIME SHIPMENT METHOD

I H K 1 Kz SAiiaPLE COWOmON SAMPLE MOTES

R Temp in °C Received on Ice Y/^ o I SAMPLER NAME AND SIGNATURE I o Sealed Cooler )/N o PRINTNameo,sampler: CO Samples Intact/^j/N LO SIGNATURE of SAMPLER: DATESiflned: (MM/DD/YY) on Additional CommonJe:

eCC OEX/Cooe laio’vrfc# »r* ORIGINAI

NYC-WTC_000224775