Chain of custody request form, Dec 2001

NYC 9/11 Public Portal Document CONFIDENTIAL, SUBJECT TO PROTECTIVE ORDER NO. 2, SEPT. 2008 CITY 21MC100 014660253 Pace Analytical" www.pacelabs.com Reguired Client Information: Section A Company® ATC Assaciater Inc Address 104 E 25th strec io th floor Required Client Information: Report To: Sames f Section B Copy To: CHAIN-OF-CUSTODY 1 Analytical Request Document The Chain-af-Custody is a LEGAL DOCUMENT. All relevant fields must be completed accurately. 623392 Page: of 1 To Be Completed by Pace Analytical and Client Section C Ounte Reference: Invoice To: Client Information (Check quote/contract): Requested Due Dater 1: *TAT: Project Manager: P.O. Project #: Phone 22:353.8286 Section D Fax 012.353.3306 Required Client Information: ITEM # SAMPLE ID One character per box. (A-Z, 0-9/.-) Sample IDs MUST BE UNIQUE Proea Namo P$: 89M Project Number 19125- P5891 H1V Valid Matrix Codes + MATAIX WATER CODE WT SOIL SL OIL OL WIPE WP AIR AR TISSUE TS OTHER OT MATRIX CODE % * Turn around times less than 14 days subject to laboratory and contractual obligations and may result in a Rush Turaround Surcharge. Turn Around Time (TAT) in calendar days. Profile #: Requested Analysis: D A 2 3 4 5 6 5 A 5 DATE COLLECTED F TIME GOLLECTED mm/dd/ yy nai taith app 12/15/51 495 432 4,36 446 Blant Preservatives # Containers Unpreserved ioyin A HCI Remarks / Lab ID plag jraim Hamas lylafeeua Rieburdos Roo Aijulede 8 9 10 11 12 SHIPMENT METHOD ed ey SAMPLE CONDITION Temp in °C AIRBILL NO. SHIPPING DATE NO. OF COOLERS ITEM INUMBER RELINQUISHED BY / AFFILIATION| DATE TIME ACCEPTED BY / AFFILIATION DATE TIME SAMPLE NOTES Received on Ice Sealed Cooler Y/N Y/N SÄMPLER NAME AND SIGNATURE PRINT Name of SAMPLER: Samples Intact Y/N Additional Comments: Batch #621- PUF Check SIGNATURE of SAMPLER: DATE Signed: (MM /DD/YY) crE REvEpCE CINE FAD INCTOlICTIANC Form COCO1 Rev 0601 NYC-WTC_000174791