Chain-of-Custody Form for PS 89M Samples

NYC 9/11 Public Portal Document

RSC PSC Analytical Services 4418 Pottsville Pike PSC Work Order # I ( S Readina. PA 19605 CHAIN OF CUSTODY * Page of i ~ phone; (610) 921-8833 ( fax; (610) 921-9667 or 921-8407 1

POtt Quote# t 1 Report Name \AA»^>A CbYv. JOB ID: ( Company T I Results Mailing Address ic, Ci itf 71- ANALYSIS REQUESTED 1

To: '/er^ state /VX ZIP Use attachments if necessary. I Telephone J 8 Please specify method requirements. Preservatives Key: G CO Name A = Ascorbic Acid t G ( M Company O C = HCI N2 = NaS2O3 H Submit Mailing Address H = HN03 S =H2SO4 H O Invoice City Stale ZIP I = Ice Z = ZnAcetate To: Fax ft

J 03 Telephone # N = NaOH X = None 23 O Credit Card Info (indude exp. date) H M Sampled by: X 'TTzuz^C Sampling Location (Specify State):_______________ 0 = Other; O O H O Due Date: (Rush TAT requires Lab approval) H S < G M H REPORTING REQUIREMENTS (Circle all that apply) a Preservatives (See above Key: O M Full Data Package Reduced Deliverables Package Electronic Data Deliverables 23 S list all that apply) a H M H UST NPDES MIPP RCRA Stormwater DEP (PWS# ) Type (P=Plastic, G-Glass, A=Air) 23 > S T SAMPLE DESCRIPTION Final Air Volumt Matrix Type I Sampling Info Container Volume (Liter, etc) O (ID must match container labels) (L or min) Date Time rvumber of Containers to ( I IL It CO 2 3 ( r 4 to o 5 t o t co 6 1 O 7 H 8 9 S Q 10 I—i o o (1) Relinquished by: Dale Time ;2) Rec^^X Dale Time (3) Relinquished by: Dale Time I o /d/ fX) o (4) Received by: Dale Time [5) Rainqiiished by: Date Time (6) Received ai Lab: Dale Time co 1 rC. rC. Method of Delivery: UPS (^FED-E^ PAS Courier Client US Mail Other CO

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