Chain of custody form, PSC Analytical Services

NYC 9/11 Public Portal Document

GJ RSC PSC Analytical Services 4418 Pottsville Pike z-i PSC Work Order #

Q- Reading PA 19605 phone (610)921 8833 CHAIN OF CUSTODY - of fax (610)921 9667 or 921 8407 PO# Quote It

Report Name JOB ID Company Results Mailing Address /=^rc r* ANALYSIS REQUESTED co cc To Cily Slate ZIP Use attachments if necessary cn I Please specify method requirements Preservatives Key Name A = Ascorbic Acid w GJ tn G ro I Submit Company C = HCI N2 = NaS2O3 G o Mailing Address H = HNO3 S = H2SO4 H O CD Invoice City state ZIP si A I = Ice ;Z = ZnAcetate A To Telephone# Fax# N = NaOH X = None O Credit Card Info (include exp dale) hd Sampled by Sampling Location (Specify state) O = Other o A M Due Date 17 (Rush TAT requires Lab approval) s O O REPORTING REQUIREMENTS (Circle all that apply) A O H G Electronic Data Deliverables PreservatIvBs (See above Key < G Full Data Package Reduced Deliverables Package H A list all that apply) a O G UST NPDES MIPP RCRA Stormwater OEP (PWS # ) Type (P^PIaslic G-Glass A=Air) pd G a A M A sUJ SAMPLb DESCRIPTION rmat Air Voluiiit Matrix Type Sampling Info Container Volume (Liter etc) G > G (ID must inaluh conlainer labels) (L -w iiffftT*’ Date Time Number of Containers G ' O 1

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Id 7 co 4) O N 8

9

lU k- \J (1) Relinquished by . Dale. - Time 11(2) Received by Date Time (3) Relinquished by Dale Time £/!■ o J) o tj (4) Received by ' Dale lime (5) Relinquished by Date Time (6) Received at Lab -J Dale Time I _____ •qW-V ) o O □ Method of Delivery UPS FED EX PAS Courier Client US Mail other o

NYC-WTC_000175419