Chain of custody form for analytical services

NYC 9/11 Public Portal Document

Chain of Custody Record Sample Container tn format/on 4418 Pottsville Pike Reading, PA 19605 ““ Bottle Type __il phone: (610) 921-8833 fax: (610) 921-9667 _ ( n P IH I *—✓ ANALYTICAL SERVICES # of Containers h IPO# Job ID Preserved? (Y/N) ■y Nams

Report Company Results Mailing Address To: City .S'/'- 7V7 Y? zvy ZIP .yy* /4? Telephone # - 6 Mame Telephone # 8z o m Send Company Dept. ZxxZ Irvvoice Mailinp Address -y'jA XWzyX CO c co m To: City Credit Card # State ZIP

Exp. Date /xxzV zz / / z y Page PAS Quote# /of / O

o Sampled by: Z* Matrix Date Time 5 SAMPLE DESCRIPTION Type Sampled Sampled o Coinments/Hazaids/Location Details rn O

m 1 A/6. Z22C/-Z Z4Z/7///yr5y ioocr?' 'fc /c»vl 5CZ O zn 2 ZZ"/A? c f Oa i o m 3 Ififf A’-oyz/v*////) - P P 4 y CO m 5

8 6 w wp /fiff'c*}' 03 7 /tSW' . 8 ■ W 4, //Jf" , - ■ / /g>g" y 9 • /< '■ ‘ r't -7 to « r /y •/. I - -/ fCi-ef ( «.Y V / z,, 7 = t zV / •

SpecialTnstructions (including Data Deliverables and Turn Around Time): ' i, 5- V

Samples relinquished to Samples Relinquished by: Samples Relinquished to: I Date Time o shipper or courier by: '^2 Samples received by: . . Date , Time Samples Relinquished by; , Samples Relinquished to I Date Time s ,y/y J I Laboratory: o Method of Shipment/Delivery: UPS /FED-EX l’AS Courier client drop off Other o Samples Rec'd. on Ice? ( Y N n/a) , Temp. Blank Sample Temp. Notes ; 'o Samples rec'd intact?(Y N ) Custody seals intact?! Y N n/a ) ID on samples match C0C?( Y N ) 8 VOC Samples have zero headspace?( Y N n/a ) Samples properly preserved? ( Y N n/a ) 00

NYC-WTC_000174800