Chain of custody form for analytical samples

NYC 9/11 Public Portal Document

RSC Analytical Services ZI 01 PSC Work Order# 1 4418 Pottsville Pike Reading, PA 19605 CHAIN OF CUSTODY w Ul Phone:(610)921-8833 Page 1 of v o fax: (610)921-9667 or 921-8407_________________ w POU Quote tt re Report Name f Ia Vk JOS ID; rd Company A-Tc- Pv-e- rd Results Mailing Address — ANALYSIS REQUESTED T3

To: City Slate ZIP/4%?/«5 Use attachments if necessary. a Telephone# ST-Jh o 2:$ 3. 27 4'4 Please specify method requirements. Preservatives Key; ■a co Name Q M A = Ascorbic Acid n o Company H Submit C = HCI N2 = NaS2O3 33 Mailing Address H = HNO3 S =HZSO4 □ H O Invoice city state ZIP 01 I = Ice

I Z = ZnAcetate rtj To; Telephone tl Fax # a N = NaOH X = None r+ O Credit Card Info (include exp. date) H n M u O O Sampled by: E Sampling Location (Specify State):_______________ O = Other; H O S nq Due Date: (Rush TAT requires Lab approval) § tn REPORTING REQUIREMENTS (Circle all that apply) a ■J M Pieseivatives (See above Key; ' < § s Full Data Package Reduced Deliverables Package Electronic Data Deliverables a H list all that apply) M 0 23 > UST NPDES MIPP RCRA Stormwater DEP (PWS # ) Type (P=Plaslic, G^GIass, A=Air) tD w 3 O 5 SAMPLE DESCRIPTION Final Air Volums Matrix Type Sampling Info Container Volume ILiter, etc) E (ID must match container labels) (L <te4»tu) Dale Time Number of Containers 0) 1 ,rry - Mi Mr HL l-cbb^ w o o M 2 -0,77- fry- <^2- u 93 H 3 fi-rc- o3l3 -iTY - rd __________ T j Ty- f to 03 O O 5 03 CO 6 Q 1 H K s I to 9 S O in o o (1) Relinquished by: Dale Time (2) Received by; Date Time (3) Relinquished by; Dale Time I o TJ o (4) Received by: Date Time (5) Relinquished by Date Time (6) Received at Lab: . Dale rims co iC. S" co <0 co Method of Delivery: UPS D-EX^I PAS Courier Client US Mail Other cn co

NYC-WTC_000175043