Chain-of-Custody Form for PS 89M Samples

NYC 9/11 Public Portal Document

RSC PSC Analytical Services 4418 Pottsville Pike PSC Work Order # Reading, PA 19605 CHAIN OF CUSTODY Phone:(610)921-8833 Page I st i fax: (610) 921-9667 or 921-8407_________________ PO# Quote #

Report Name 3 f*JVV<A-» C r3 k tv ID; Company TVT C- AiJrO f p.V<- Results Mailing Address ANALYSIS REQUESTED {g Cy i /a TH. To: State /a^/o Use attachments if necessary. co Telephone# a;\^ . Please specify method requirements. G S3 o 6 Preservatives Key: G Name A = Ascorbic Acid G W Company O H Submit C = HC1 N2 = NaS2O3 Mailing Address H = HNO3 S «H2SO4 H Invoice city state ZIP I = Ice Z = ZnAcetate O G To; Telephone # Fax# N = NaOH X = None W O H W Credit Card Info (include exp. date) 1 1 Sampled by: Sampling Location (Specify State): O = other: O O H O Due Date: (Rush TAT requires Lab approval) < M §H REPORTING REQUIREMENTS (Circle all that apply) a Pr^ervattves'(Sae above Key; O M Full Data Package Reduced Deliverables Package Electronic Data Deliverables w s list all that apply) a H ^(P=PlastK, G^GIass. A=Air) M w H > UST NPDES MIPP RCRA Stormwater DEP (PWS# ) s T I o s SAMPLE DESCRIPTION Final Air Volum< (ID must match container labels) (L or min) Matrix Type Sampling Info

Date Time Container Volume (Liter, etc)

Number of Containers to 1 Arc- 57^7 Arj- /J/-. w 2 M 3 H 4 ( I N) O 5 O CO 6 t O ( 7 ! H c ND 8 9 S o 10

o o (1) Relinquished by: Dale Time (2) Received by: Date Time (3) Relinquished by: Date Time I o o (4) Received by: tz Dale Time (5) Relinquished by: Dale Time (6) Recaaed a^b: , Z .pate. Time co ///^ f NO Method ot Delivery: UPS FED-E PAS Courier Client US Mail Other r

NYC-WTC_000177732