Chain of Custody Form, PSC Analytical Services

NYC 9/11 Public Portal Document

w RSC PSC Analytical Services 4418 Pottsville Pike _ PSC Work Order# Q. Reading, PA 19605 phone: (610) 921-8833 CHAIN OF CUSTODY Page | of 1 fax: (610) 921-9667 or 921-8407 PO#____________________________________________ Quote #

Report Name ~ JOB ID: - Company cTcctCs T-Vhc._____________________________ C^ Results Mailing Address |o(^ ipTC ANALYSIS REQUESTED CO CD To: City stale /// 2IP A&/O Use attachments if necessary. 0) I -Telephone#^!#. KJ . Please specify method requirements Preservatives Key: w G CM Name A = Ascorbic Acid CO m G M O □ I Submit Company C = HCI N2 = NaS2O3 Malling Address

I H = HNO3 S =H2SO4 H UJ Invoice city Slate ZIP I = Ice Z = ZnAce tale H O To: Telephone ft Fax# N = NaOH X = None no Credit Card Info (include exp. date} V o H Sampled by: X'T^T-w Sampling Location (Specify Slate): O = Other:

I M O O Due Date: V (Rush TAT requires Lab approval) H O H S REPORTING REQUIREMENTS (Circle all that apply) < G M Hl PtBSBivslivas (Sae above Key; D Full Data Package Reduced Deliverables Package Electronic Data Deliverables O M list all that apply) 03 S a H UST NPDES MIPP RCRA Stormwater DEP (PWS# ) Type (P=P:3Stip G-Glass, A-Airj M Hl ?0 > rtt

S ' 2 SAMPLE DESCRIPTION Final Air Votiinu Matrix Type Sampling info Container Volume (Liter, etc)

o (ID must match co nt a i tier labels) (L H.wi») Dale Time Number of Containers

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o (1) Relinquished by: Dale Time (2) Received by: Date Time (3) Relinquished by: Date Time I o tn o □ (4) Received by: Data Time (5) Relinquished by: Date Time t6J Received at Lab; i co CO O tn 0. (U —(--------------------------------------------- ------------------ ncirr.-------------------------------------- ___ r iw Oh Method of Delivery: . UPS zKeD-E^ PAS Courier Client US Mail Other ___ kO kO

NYC-WTC_000175228