Chain of custody form, PSC Analytical Services, Aug 2002

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o I PSC Analytical Services o co OJ 4418 Pottsville Pike § c o o Q. Reading, PA 19605 phone: (610) 921-8833 fax: (610) 921-9667 or 921-8407 CHAIN OF CUSTODY “0 c CT o' "0 cn PO# Quote # o 00 GO Report Name C fT v\ JOB ID: 3^^ 9L Company AYc, 'Kst o VM? , O o Results Mating Address o U) jy-fL 5Vyz^-.-X^ ANALYSIS REQUESTED c co cn To: City Slate Use atiachments if necessary. .3 CD 3 Telephone Please specify method requirements. Preservatives Key; w N Name A = Ascorbic Acid G cn co Ct G I Submit Company O w C = HCI N2 = NaS2O3 □ 0 qM Invoice Wailing Address H = HNO3 S =H2aO4 u a5 state ZIP Vt s I = Ice 2 = ZnAoetete H To: N o no Telephone tf Credit Card Info (include exp. date) Fax U 4 N = NaOH X = None '

V .5 I o Sampled by: Jit, Sampling Location (Specity Stale): X O = Other: H M Due Date: _____________________________ (Rush TAT requires Lab approval) O O H O REPORTiNG REQUIREMENTS (Circle all that apply) H S < G PreservTlives (S'ee'abovEKey: M Hl Full Data Package Reduced Deliverables Package Electronic Data Deliverables a list aH that apply) O H 03 S UST NPDES MtPP RCRA Stormwater DEP (PWS# ) Type (P=Plasl!C, G^GIass, A=Air} a H M HI ?0 > 5? U) SAMPLE DESCRIPTION Final Air Vohimt Matrix Type Sampling Info Container Volume fUter, etc)

S ' (fD must match container labels) (L -tn urrT) Date Time Number of Containers o ! /4>Xg to 2 p W H U m If 3 - 5^ /iS A Va el d3 n. IS 4 H 5 to o 6

s qH 10 (b 7 w B l"^ to O 9 Hi s 10 o w o o (It Relinquishedby-r-y"^ Date Time (2) Received by: Date Time (3) Relinquished by: Date Time o I o d) □ sUiJez, (4) Received by; Date Time (5) Relinquished by: Date Time {6J Received at Lab: . o co IC. Q. HI Jj______ (> — co cn FED-EX ) PAS Courier o Method of Delivery: UPS Client US Mail Other cn o CD