Chain of custody form for water and soil samples

NYC 9/11 Public Portal Document SUBJECT PROTECTIVE ORDER NO. SEPT. 2008 CONFIDENTIAL, CITY_21MC100_003431906 Pace Analyticar www.pacelabs.com Required Client Information: Section A Company Aic Asocaie ine Address io4E25th street !Táf'a... Required Client Information: Repori To: James!ohn Section B Copy To: CHAIN-OF-CUSTODY 1 Analytical Request Document The Chain-of-Custody is a LEGAL DOCUMENT. All relevant fields must be completed accurately. 615855 Page: / of To Be Completed by Pace Analytical and Client Section C Quote Reference: Client Information (Check quote/contract): Requested Due Date: *TAT: invoice To: P.O. Project Name: <94 M Project Manager: Project #: * Turn around times less than 14 days subject to laboratory and contractuai obligations and may resutt in a Rush Turnaround Surcharge. Turn Around Time (TAT) in calendar days. Profile #: Phone Fax 2123i1810215153.8106 Section D Required Client Information: Project Number: 14195-0190 Valid Matrix Codes 4. MATRIX WATER CODE WT SAMPLEID SOIL SL #W31I OIL OL WIPE WP One character per box. (A-Z, 0-9/.-) AIR AR TISSUE TS Sample IDs MUST BE UNIQUE OTHER OT - 1229- 4 P 2 3 4 5 6 7 8 9 10 11 12 A S-: 229 - 894 M - P2 -1229-894M- P9 -1229- q4 fi- 1229-81 2 89 4 M-O 22 -8 9 4 M- 8" 8 8 192 84 4 M-P Requested Anaiysis: Preservatives 10x:+ mm / dd / yy iagaia I6T: bel 301 mtim aip 452.4 4/8.4 488.5 6259 445.1 4$4.5 443.0 413.1 479.5 Blauk Remarks / Lab ID Lat,ary igtt fler Lobky Mai Cntrauke / 3ad Flor-Malny boy fyie vitterRm11e6S Roowa 503 Sthflor tm Ti5 iihdlor s Rm 903 aT farr N Root by Irtak autelors MarEnt. SHIPMENT METHOD AIRBILL NO. Mel SHIPPING DATE INO. OF COOLERS ITEM NUMBER RELINQUISHED BY I AFFILIATION DATE • TIME ACCEPTED BY / AFFILIATION DATE TIME SAMPLE CONDITION Temp in °C Received on Ice IY/N Sealed Cooler Y/N Samples Intact | Y/N Additional Comments: SAMPLE NOTES SAMPLER NAME AND SIGNATURE PRINT Name of SAMPLER: WAGDT SIGNATURE of SAMPLER: Hopet DATE Signed: (MM/ DD / YY) 12/29/01 NYC-WTC_000175599