Chain-of-custody form for environmental samples, ATC Associates, 2002

NYC 9/11 Public Portal Document 800Z CONFIDENTIAL, CITY_21MC100_003432599 Pace Analytical™ www.pacelabs.com Required Client Information: Section A Company АTС Associate lie Copy To: Address 104 E2512 stret invoice To: 1oT flour NY /00/6 Phone Fax 211.353.8280 212.353.8306 Section D Required Client Information: Requlred Client Information: Report To: Jame Section B Cohn The Chain-of-Custody is a LEGAL DOCUMENT. All relavant fields must be completed accurately. 625144 Page: 4 of 1 To Be Compleled by Pace Analylical and Client Section C Quote Reference: Client Information (Check quote/contract): Requasted Due Date: TAT: Project Manager: Projoct#: 1058894 ITEM # 2 3 A ATC-051 Project Name: slfyvezat. Hs Project Number: 14125-0246 Valid Matrix Codes 4 MATRIX CODE SAMPLEID WATER SOIL WT SL UIL OL WIPE WP One character per box. (A-Z, 0-9/ .-) AIR AR TISSUE TS Sample IDs MUST BE UNIQUE OTHER • OT 05 15 57У- Y 5 - TY - x2 5-STY-=X3 + Turn around times leas than 14 days subject to laboratory and contractual obligations and may result in a Rush Turnaround Surcharge. Turn Around Time (TAT) in calendar days. Profile #: Requestad Analysis: MATRIX CODE wp DATE COLLECTED mm / dd / yy WP|5/15/12 TIME COLLECTED AACElp Im2 Preservatives # Containers H,SO. HNO, HCI NaOH Other Dioxin Наї -Lably Wall. Bridae Eut fobly wall C HVACD Remarks / Lab ID 3580015 3580003 3580031 7 8 10 11 12 SHIPMENT METHOD Fedex SAMPLE CONDITION Temp in °C Received on Ice AIRBILL NO. ITECI SHIPPING DATE NO. OF COOLERS NUMBER RELINQUISHED BY / AFFILIATION DATE TIME ACCEPTED BY I AFFILIATION K-Bank DATE { TIME Spabal:a SAMPLE NOTES Sealed Cooler DNN Samples Intact Additlonal Comments: ORIGINAL SAMPLER NAME AND SIGNATURE PRINT Name ol SAMPLER: SIGNATURE o SAMPLER: Waqei rtospot CFE REVEDCE CINE EMD INICTDIINTIANIC TDATE Signed: (MM/DD/YY) Camm rArn o NYC-WTC_000175715