Chain of custody form for air sampling, ATC

NYC 9/11 Public Portal Document

PSC AIR SAMPLING PSC Work Order #

CJ 4418 Pottsville Pike phone. (610) 921 -8833 CHAIN OF CUSTODY Page J of 0. Reading, PA 19605 fax: (610) 921 -9667 ss [Ipo # Quote # IjName iName CfyvWX Report pmpany A'TC 7 ~ Submit , . EMailing ----- Rni rTrI» ( x ”Address Results iMailing Address \Ql-\ Invoice _ H------ --- Ipty State ZIP €0 To: City_________ __________________ State .^4 ZIP_________ fO' ||Telephone # Fax # CD m [Telephone # AsA- ^25^ ^ax it ^1^ [[credit Card Info (include exp date) w G 04 CO G m COMMON MATRIX TYPES Job/Project Name:_______ tA,________ M I □ 1 Badge (OVM/Passive Monitor) 6 Wipe (specify type) Sampler’s Name(s): qH | ~T^ia2.\.v\ O H ID 2 Tube (specify type charcoal, silica, XAD, etc) 7. Tedlar Bag Sampling Location (Specify State): U H O 3 Train (filler + tube, 2 tubes in senes, etc) SSumnia Can Due Date (Rush results requires Lab approval): 03 33 4. Filter/Cassette (specify PVC, MCE, OFF, etc) 9 PUF/Resin/XAD REPORTING REQUIREMENTS (Circle all that apply): O H 5. Impinger Solutions (specify componenls) 10, Other (hs( details) Full Data Package Reduced Deliverables Pkg Electronic Data Deliverables M O o H o 2 FINAL AIR G M * MATRIX MEDIA SAMPLE FLOW RATES ANALYSIS REQUESTED a SAMPLE DESCRIPTION VOLUME SAMPLE O H (list catalog (specify: TIMES a 2 H (see above DATE (specify units ) Uis attachment\ if necessary M (ID must match container labels) list) number) minutes, etc) Start Stop Initial Final Average Please specify method requirements a o & 2 I ATC-cAQ - KT-MfA- Ugsi 32G-I7- LT ISLQ Stop ka\Ot Q.-X SS sz UXx-CvA, ATc. -lPiO A^uivy-- Ha a. Q a ri..2 ND 3 ATO - cTi mg m- 'xMO AsAIO Q.l co CJ »> 4 Ayl • i5i I v\' V V Y 5 H tn 0. 6 ro 7 o o co 8 9 H in 10 ciiQ (1) Relinquished by _ I / Time (2) Received by Date ! g ____________ / Date I 7//2 Time

o O |> ~ (3) Relinquished by Dale Time (4) Received by

S a- __________ ________________ u,. W _____ 7 ” Method of Delivery: UPS FED.EX PSC Courier Client US Mail (^Ihor

NYC-\/VTC_000175540