Chain of custody form for PSC Analytical Services

NYC 9/11 Public Portal Document

PSC Analytical Services CM 4418 Pottsville Pike PSC Work Order#

(t Reading, PA 19605 phone: (610) 921-8833 CHAIN OF CUSTODY Psgs I of I fax: (610) 921-9667 or 921-8407 POg Quote

Report Name JOB ID; 5

Results Mailing Address Atc A&jhrAoX, Company

CD J? / ANALYSIS REQUESTED CD CD To: Ci»zt4«u Zd4A Stale ZIP /rX>/0 Use attachments if necessary. I Telephone# & US 0 Please specify method requirements. Preservatives Key: tu Name A = Ascorbic Acid G 01 tn Company C = HCi N2 = NaS2O3 G th □ Submit Mailing Address H = HNO3 S = H2SO4 O H u> Invoice State ZtP I = lce Z= ZiiAcetate H O To: Telephone# Fax# N = NaOH X = None hd Credit Card Info (include exp. dale) V o Sampled by: Sampling Location (Specify State): / 0 = Other: H th o H

< th o o 3 3 Due Date;

Full Data Package (Rush TAT requires Lab^ approval) REPORTING REQUIREMENTS (Circle alt that apply) Reduced Deliverables Package Electronic Data Deliverables I PresetvativBS (Sie above Key; li^all^stapply} a o th ?n 3 UST NPDES MIPP RCRA Stormwater DEP (PWS# ) Type !P=Pl3Stic, G-Glass. A’^yyr) a H th =tt ?n > G 5 Lt: SAMPLE DESCRIPTION Final Air Volume Matrix Type Sampling Info Container Volume (Liter, etc) s (]D must match conlatner labels) (L or min) Date Time Number of Containers o I to 2 co U 3 01 0. 4 5 to o 6 o Q G. co r* 7 H tu 8 W I—i □ s O tu 10

o o (1| ReSnquished by: Date Time 11(2) Received by: Dale Time (3) Relinquished by: Date Time o 0) I w (S) Received at 1^^^ o (4) Received by: Dale Time )i(5) Relinquished by: Date Time o co U> 44^ CO □ CE O Method of Delivery:. UPS ED-EX PAS Courier Client US Mail Other CO

NYC-WTC_000175133