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Chain-of-Custody Form for Analytical Request

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Legal chain-of-custody document for environmental samples submitted to PSC Analytical Services.

NYC-WTC_000177715
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NYC 9/11 Public Portal Document

CHAIN-OF-CUSTODY / Analytical Request Document The Chain-of-Custody is a LEGAL DOCUMENT. All relevant fields must be completed accurately. ^ceAnalyticaT Section B www.pacelab5.coin Required Client Information: Report To: A Page: | of ( 625143 Required Client Information: Company , , Section A »- Copy To: oU To a© Completed by Pace Analytical and Client Quote Reference: Section C Client Information (Check quole/contract): Invoice To: Requested Due Dale: *TAT: Project Manager:

RO. Project #: * Turn around times less than 14 days subject to /Z>Z/ laboratory and contractual obligations and may result in a Rush Turnaround Surcharge. Profile #: Turn Around Time (TAT) in calendar days. Phone Fax Project Number: Requested Analysis: ^1^. Y? f o Section D Required Client Information; Valid Matrix Codes Q Q Preservatives MATRIX CODE LU UJ WATER WT LU e; o U O SAMPLE ID Q

i SOIL SL ■s a OIL OL O O o J X * WIPE WP X o o" o§ .0 Q One character per box. AIR AR o o X M 2 a H UJ H (A-Z, 0-9 / .-) Sample IDs MUST BE UNIQUE TISSUE OTHER TS OT § mm / dd / yy hh;mn] a/p O Q. C * D X X X 2 2 o I o .c O / Remarks Z Lab ID

H O IS c o ( A 5 8. i X t-j / Al^ v { J - Z (6 ■ /

X X O A r IS A Si Mi / n;'' v {( z - Se w# t /f/zL-b- f/. <7 I H S M /I T c IM -3 f hl Q Q H O s lA T c o I <5 g P ft V ii t/ /-A < a i o M 'j.Z XI 3 > u H a M X > - J f s o

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■ O O CO SHIPMENT METHOD AIRBILL NO. SHIPPING DATE NO. OF COOLERSLjj^ RELINQUISHED BY I AFFILIATION TIME ACCEPTED BY/AFFILIATION BIB o P~-p -iZ z H SAMPLE CONDITION Temp in °C SAMPLE NOTES

S Received on Ice Y/N O o Sealed Cooler Y/N SAMPLER NAME AND SIGNATURE o PRINT Name of SAMPLER: I o Samples Intact Y/N CO SIGNATURE of SAMPLER: DATE Signed: (MM / DO / YY) Additional Comments; co co <3 <?PP RFt/FR<iP «;inp PAR IMQTRI irTinMQ Form COC01 Rev 0601 co

NYC-WTC_000177715

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NYC-WTC_000177715Source: NYC Law Department, mirrored locally

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