Chain of custody form for PSC Analytical Services samples

Z o □ F=sc: PSC Analytical Services 4418 Pottsville Pike f-s. _ P^C Work Order # 5 § Reading, PA 19605 CHAIN OF CUSTODY CD

s Q. phone; (610) 921-8833 Page I of' ■D c o fax: (610) 921-9667 or 921-8407 CT o o' PO # Quote U ■D cn bJ Name James Cohn JOB ID: 19125- b O 3. Company ATC Associates Inc. 92. Results Mailing Address 104 E 25th Street O ANALYSIS REQUESTED o o U) CD To; City NY stale NY ZIP 10010 Use attachments it necessary. c 0) 3 I Telephone fi (212) 353 8280 Fax# (212) 353 8306 Please specify method requirements. Preservatives Key: CD

CO Name A = Ascorbic Acid N G 0} Company CO I Submit SAEt, C = HC1 N2 = NaS2O3 G M □ Mailing Address H = HNO3 S =H2SO4 O Invoice (5ity Slate ZIP H CO l = lce Z = ZnAcetate To; 4^ H Telephone # Fax# N = NaOH X = None O Credit Card Info (include exp. dale)

i k G XI Sampler! by. J Sampling Location (Specify Stale): [gy 0 = Other: O H M Due Date: / (Rush TAT requires Lab approval) a o REPORTING REQUIREMENTS (Circle all that apply) H § < N Full Data Package Reduced Deliverables Package Electronic Data Deliverables Preservatives (See above Key: M H list all that apply) O O M UST NPDES MIPP RCRA Stormwater DEP (PWS # ?d a ) Type (P=Pl8Slic. G-Glass, A'^AIr) a A % M 73 H > 2 SAMPLE DESCRIPTION Final Air Voluint Matrix Type Sampling Info Container Volume (Liter, etc)

S ' (ID must match container labels) (L jot-wniT) Dale Number pt Containers O I 7?^ ^2^ to 2 A Tt<-C Ul-f 2 V co 3 ~VY>C.2 l/ b'-i (J M V) f ::7 CT TJ 4 0. 5 to 6 o o co n 7 O * R A 9 tn o 10 to OJ G a (1) Relinquished by: ■ Date, Time |2) Received by: Date Time (3) Relinquished by: Date Time O o o o n (4) Received by: □ate Time (5) Relinquished by: Date Time (6) Received al Lab: Time I o (10 o □ co ■''FED-EJiZ PAS Courier Client US Mail z/Cther ft- CE Method of Delivery: UPS to

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