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INDUSTRIAL HYGIENE SAMPLE RECORD FORM
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SAMPLING DESCRIPTION
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DESCRIPTION OP WORK`_________________
DEPARTMENT SECTION__
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PUMP / DOSIMETER I___________________________
PLOW RATE .______________
LITERS OR MLITERS________
CALIBRATION DATE_____ /____ /_____ _
PER MINUTE
NOISE THRESHOLD
FIRST STARTING TIME_____ :______ NEW STARTING TIME_____ :______
PIRST STOPPING TIME SECOND STOPPING TIME
i______ t______
TOTAL TIME_________ MIN VOLUME._______________ LITERS
TYPE OP COLLECTING DEVICE_____ DEVICE NUMBER_____________________
WERE PROTECTIVE DEVICES USED? TYPE OP EAR PLUGS................ TYPE OF EAR MUFFS................ TYPE OF GLOVES....................... NIOSH RES?. APPROVAL *.. OTHER.............................................
ANALYSIS REQUESTED (SPECIFY CONTAMINANT(S)
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PINAL REMARKS:
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PLEASE CONTACT THE FOLLOWING INDIVIDUAL WHEN ADDITIONAL SAMPLES ARE NEEDED OR QUESTIONS ON ANALYSES ARISE: Robert Lieckfield, Manager, Laboratory Services, Clayton Environmental Consultants, Inc. Phone: (313) 424-8860.
IP QUESTIONS ON INTERPRETATION OP RESULTS ARISE, PLEASE CALL CORPORATE INDUSTRIAL HYGIENE - WIN 236-1364 or BELL (412) 256-1364.
RY 16, 1985
OVER -
Mark A. Perriello, CIH Senior Industrial Hygiene Engineer
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Clayton Environmental Consultants, Inc.
25711 Southfield Road Southfield, Micnigan 48075 Telephone (3131 424-8860
LAttORATUKY REQUEST
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Company: WESTINGHQUSE ELECTRIC CORPORATION______________
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Sampling DateQivJ\Y> ' <~~~^tc> tt^ 1a. Sampling .Media:
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Sample Description___________
Air Volume (give units!
Analyses Requested
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5f? -cial Instructions (method, limit of detection) /a/^/kr
Send copy of aJl
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Mark
Perrlello. Pittsburgh, PA
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