Chain of custody form for PSC Analytical Services

NYC 9/11 Public Portal Document

CD Rsc: PSC Analytical Services 4418 Pottsville Pike EL Reading, PA 19605 phone: (610) 921-8833 CHAIN OF CUSTODY Page - I ot -J, fax: (610) 921-9667 or 921-8407 PO# Quote # .XT QAv. JOB ID; ^Q \ 0 3^^ Report Name Company r- Results Mailing Address _L:A.cr_ J tA.C ANALYSIS REQUESTED (D iG U <S 1qT\ re­ CD D} To: cily state yr /ZIP Artrcj/ct Use attachments if necessary. I Telephone#^J^^_jS2L_£2J22L__.52J^^ Please specify method requirements. Preservatives Key:

w tu Name A = Ascorbic Acid DI G Company C=HCI N2 = NaS2O3 ro G □ I Submit Mailing Address H = HNO3 S = H2SO4 M O w Invoice ci;;^ stale ZIP l = lce Z = ZnAcetate H H To: Telephone It Fax 7 4 N = NaOH X - None O Credit Card Info {include exp. date) G V O Sampled by; Sampling Location (Specify State):_______________ ’S h 0 = Other: H Due Date; (Rush TAT requires Lab approv^ M O O REPORTING REQUIREMENTS (Circle all that apply) H O H S Full Data Package Reduced Deliverables Package Electronic Data Deliverables Preservatives (See above Key: < G M Hl list all that apply) a O M UST NPDES MIPP RCRA Stormwater DEP (PWS# Type (P^PIaslic. G-Glass, A-Air) G s a H SAMPLE DESCRIPTION Final Air Volume Matrix Type Sampling info Coctsiner Volume (Liter, etc}

I M Hl G > G (ID must match container labels) (L Of nriti) Date Time Number of Containers S ' O t 1 /^O to 2 1^0 A- cj p c -fr ill. C> 4> w u 3 /^O M nj 0. 0 4 /frc-6^ 2/^136M n 3 to 6 o a. 7 s q H CD tn 8 l"^ 't 9 to □ I—i to S OJ O □ (1) Relinquished by: ., , Time (2) Received by; Dale Time (3) Relinquished by: Date Time o o o ________ I n (4} Received by: Date Time (5) Relinquished by: Date Time (5) Received al lsb;^^^^ o o U) co □ CO CE Method of Delivery; UPS (gED-EX^ PAS Courier Client US Mail Otheit o NO

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NYC-WTC_000175132