Chain of custody form for analytical services

NYC 9/11 Public Portal Document

F5C 4418 Pottsville Pike Chain of Custody Record Reading, PA 19605 Bottle Type Samp/e Contamer /nformation Cu □ □ phone: (610) 921-8833 fax: (6101 92V9667 I G P IH ) 03 ANALYTICAL SERVICES # of.Containers -J—- — D ro Preserved? (Y/N) CD ro Report Company a Results Mailing Addrasa g, 1 oTR ^X»o A T3 To: State yv/y

T3 5 CD Name Telephone n o o Company Dept, z Send o □ m z Invoice Mailing AddiIress 01

tc co To; City State ZIP ft c 03 m Credit Card # Exp. Date PAS Quote# n o ai Sampled by: Air Vol. CL Mattis Dale Time o or mln) Type .Sampled Sampled y/ Coinments/Hazards/ Location Details 03 5o SAMPLE DESCRIPTION m T o 1 *^1 air lA hi ^oo 7^00 / fa,^ iKlAka, < m 2 4Tc- 1415- STM- A42 / iz5O 0 O ID zn o m jj 3 4^0.. (Xt^- Ms Ll^ W

P 4 jgMxr P CO 5 m 6 8 □ 03 7 CD r\) 8 03 9 0) OJ 10 Special Instructions (including Data Dciiverabics and Turn Around Time):

Samples Relinquished by: Samples Relinquished to: I Dale I Time o

'I s o Samples received by:

Method of ShipmentZDclivcry: UPS FED-EXJ) PA^i Couner Time Samples Relinquished by:

Client drop otf Other I Samples KelinquisbciPto I Laboratory: x Date I Time

T) o Samples Rec’T^^ Ice? ( Y N^/a)/ Temp. Blank Sample Temp. Noles: 'o Samples rec'd intaift^^N ) Custody seals intact?! Y iF on samples match C0^^y)n I ro VGC Samples have zero headspace?! Y N/Sl'J ) Samples properly preserved? ( Y N ^/a^ 8

NYC-WTC_000174790