Chain-of-Custody Form for PS 89M Samples

NYC 9/11 Public Portal Document

R5CZI PSC Analytical Services 4418 Pottsville Pike - MC Order # Reading, PA 19605 phone: (610) 921-8833 CHAIN OF CUSTODY Page 1 Of L fax: (610) 921-9667 or 921-8407 PO^! Quote #

Name C^O Vvw ____________ JOB ID: Report Company NTTc- -Mtnc-t'oTU Tu-c.________________________ Results Wailing Address (ClL)- C /OJT- ANALYSIS REQUESTED To: State ZIP /QO/O Use attachments if necassary. Please specify method requirements. Telephone it 3^ 7. .2 2-2' Preservatives Key; Ln Name G A = Ascorbic Acid tD G H Submit Company C = HCI N2 = NaS2(i3 O Mailing Address H = HNO3 S = H2SO4 H Invoice City state ZIP -d l = lce

3 Z = ZnAcetate H O To; I Telephone#____________ _ Fax# N = NaOH X = None G Credit Card Info (include exp. dale) W O Sampled by: Sampling Location (Specify State):_________________ '0 = Other: H M ■ Y

<s Due Date: (Rush TAT requires Lab approval) O O H O REPORTING REQUIREMENTS (Circle all that apply) H 2 < G M H Full Data Package Reduced Deliverables Package Electronic Data Deliverables Preservatives (See above Key: a list all that apply) O M w a UST NPDES MIPP RCRA Stormwater DEP {PWS# ) Type (P^PIaslic, G=Glass, A^Air) o G M H w > =55 2 SAMPLE DESCRIPTION Final Air Vo luma Matrix Type Sampling Info Container Volume (Liter, etc) a o ' fc (ID must match container labels) (L Date Time Number of Containers_________ ( to 1 aii< 4(^11 tJtUjl'rZx

2 Ln ( M 3 I h3 H 4 I .5 ( to o 0 ( o co O H G S 9 ND in S o (3) Relinquished b^T o nTR^ioqUis^^ Dale Time 1(2) Received by: Date Time Date Time 1*^ (4) Received by: Dale Time 1(5) Relinquished by; pate Time (6) Received at Lab: o

Msthod of Dslivsry: UPS ( FED-EX^n pas Courier Client US Mail Other Ui

o

NYC-WTC_000177731