Chain of custody form for analytical samples

NYC 9/11 Public Portal Document

----------- --------------- ---------- -------------

Chain of Custody Record Sampte Container Information 5 111

BwawawMuaiM^ 4418 Pottsville Pike Reading, PA 19605 Bottle Type __r ItUJIUWirWWJPIIMJII II Illi I I * phone: (610) 921-8833 fax; (610) 921-9667 ( G P IH 1 Ht ANALYTICAL SERVICES # of Containers □ ro ~ Ipo# Preserved? (Y/NI (=> □ Nsma Report Company Co □ . □ Results Mailinfl Add,eso TJ (C’T'* To: /Zr’rtA /t7r'A state w TI G TelephanB|^^ tn W G n M Name Telephone H O T H Dapt, □ H O Send Z 1’ lU >-> Invoice Address u ns ft 50 O To: City State ZIP /^}Pags7 V. of I " t-*-

0 H (U Exp. Date M O O Credit Card # PAS Quote# H O Hl 2 Sampled by: J[(/ AlrVBL(L Matrix Date Time ’t W 3a SAMPLE DESCRIPTION oe iiiinj" Type Sampled Sampled A/l (Zas Comments/Hazards/ Location Details ID

o M C 50 a a A t ' /JT n M Hl /[/---dioyT }'ry- /VIJL C-rJpRxj n a > 2 w a o ' e 3 /?7c ,o[oj- f TY - Koo / CtTv 4 51 tu*ft. it p-4 SUtuK. m 5 w a H 6 tc nj w 7 I-*

tc to R m o tn o 9 -J co O 10 A Special Instructions [including Data Deliverables and Turn Around Time): A I to Samples relinquished to Samples Relinquished by: Samples Relinquished to: I Dale I Time ao shipper or courier by: I Samples received by; Time Dale Samples Relinquished by: Samples RelinquWied to « t Date Time 5? o ______ Laboratory; >/T'----- ^*71 I Method nf Shipmcnt/Delivery: ~DPS QFED-EX^PA3 Courier Crienl drop uff Other I ,r:,: 1,1 / TJ o ro co A Samples Rac'd, on Ice? ( Y NZn/a) Temp. Blank ______ Sample Temp. NoIes ; to Samples rec’d intact^{^,N | CustMy seals intact?( Y | ID on samples match COCji^y^^) A to VOC Samples have zero headspace?) Y Sampfes prnnerlv presert'eri? I Y A

NYC-WTC_000175036