Chain-of-Custody Form for PS 89M Samples

NYC 9/11 Public Portal Document

D RSC PSC Analytical Services 4418 Pottsville Pike PSC Work Order # Q. Reading, PA 19605 CHAIN OF CUSTODY phone; (610)921-8833 Page G of I fax; (610) 921-9667 or 921-8407 PO# Quote #

Report Name V>A..3Cz1 V \\ »i___________________________________ JOB ID: O Company •(Vi\v r^.btziL I.Ye_____________ Results Mailing Address ANALYSIS REQUESTED to C? zZ.<TU- ffUiuX- n- to cn To; City . state ZIP /eciye, Use attachments if necessary. I Telephone Ptease specify method requirements. Preservatives Key: w w Name A = Ascorbic Acid G CO tn -L G M o I Submit Company C = HCI N2 = NaS2O3 Mailing Address O H CD Invoice City ZIP zq H = HNO3 S = H2SO4 State I = Ice Z = ZnAcelate H O To; Telephone# Fax# N = NaOH X = None G XI O Sampled by: Credit Card Info {include exp. date) Sampling Location (Specify State):_________________ i 0 = Other: H M Due Date; (Rush TAT requires Lab approval) >< a o H o REPORTING REQUIREMENTS (Circle all that apply) H G < G M H Full Data Package Reduced Deliverables Package Electronic Data Deliverables Preservatives (See above Key; U list all that apply) O M X U S H UST NPDES MIPP RCRA Stormwater DEP (PWS # ) Type (P-PtasOc, G=Giaas, A-Air) CO Hl ut X > s SAMPLE DESCRIPTION Final Air Volume Matrix Type Sampling Info Container Volume (Liter, etc) G > (L or mill) Date Time O (ID must match container labels) Number of Containers 1 , ficll ffivCi-t, to

co O 3 W nd 4 0. 5 to o 6 o co QL O N O S A A tn 9 I to o

I o pj o t\l 10

(1) Relinquished by: z- Date Time (2) Received by: Date Time (3) Relinquished by; Date Time

I o w (4) Received by; t/ Date Time (5) Relinquished by; Date Time (6) Received at Lab; , Date Time o J) I co 43 4^ r Method of Delivery: IJ.PS FED-EzX P,zkS Courier Clisnt US Mail Other Ui to

NYC-WTC_000177733