Chain of custody form for analytical services

NYC 9/11 Public Portal Document

Chain of Custody Record Sample Container Information 4418 Pottsville Pike Reading, PA 19605 ““ Bottle Type _j, phone: (610) 921-8833 fax: (610, 921-9667 I C p IH I / ro ANALYTICAL SERVICES # of Containers l~t> O |po it “Q Preserved? (Y/N) CZ^ Name ______ _ a Report Company UI

Results Mailing Addieas - m □ To: •5/ TJ 4/^ rl/ y fT^ofo Telepbona g Fax Tl Mams Telephone # tn o o n z Dept. o m Send □J 3 z Invoice Vlaillng Address QI

co To: City State ZIP /jPage^^TfZ t£ c ft co Credit Card # Exp. Date m PAS Quote# o 0 -( Sampled by: ' at o Air Vol. (L Mairis Dale rime ZD SAMPLE DESCRIPTION or min) type Sampled Sampled omments/Hazards/ Location Details tn (D ) o m JJLlL 1^1 T C O ZD 2 iULL n O m ZD 3 ILRL IOC (D w z p N 4 J ld± w m 3 6 m ro o § 7 □ to ru 8 I tn I 9 tn m 10 -J Special Intfruclions (including Data Deliverables and Turn Around Time):

Samples relinquished to ./I- Date Time Samples Relinquished by: Samples Relinquished to: j Date I Time O shipper or courier by: Q O I// Samples received by: I Date I Time Samples Relinquished by: Samples RelinqpWKS’to Z' /.Date , Time 'n, Laboratory: O Method orsiiiptncntZDeiivery': UPS PAS Courier Client drop off Other

I o> Samples Rec'd. on Ice? (Y Samples rec'd intact?^ N I Temp. Blank CustMy seals intact?) Y Sample Temp. ID on samples match C0C|X; ) Notes : ■a

O) VOC Samples have zero headspace?) Y Samples properly preserved? ( Y N fn/a o ro GO ai

NYC-WTC_000174783