Chain-of-Custody Form for PS 89M Samples

NYC 9/11 Public Portal Document

N RSC PSC Analytical Services 4418 Pottsville Pike PSC Work Order# (L Reading, PA 19605 CHAIN OF CUSTODY phone; (610) 921-8833 Page J of । fax: (610) 921-9667 or 921-8407 Quote #

Report Name . CJq \\v^ JOB ID: Company AATC Cz-cX--. r- CD Results Mailing Address \ q (n > ANALYSIS REQUESTED CD (7) To; CllyX><a^ Xo/'-X. SUte ZIP Use attachments if necessary. I Please specify method requirements. w Telephone ff,jl n-^-^9 Z .7 2 C-/-. Preservatives Key: G cu Name to A = Ascorbic Acid G cn i Company C:=HC1 N2 = NaS2O3 M O □ Submit H Mailing Address H = HN03 S =H2SO4 co Invoice city state ZIP I = lce Z = ZnAcetate

1 o To: Telephone # Fax# N = NaOH X = None hd w Credit Card Info {include exp. date) o H Sampled by: Sampling Location (Specify State); 0 = Other: H O H O O Due Date: ~T7 (Rush TAT requires Lab approval) I < G REPORTING REQUIREMENTS (Circle all that apply) H H Prese^at^a'^ee'abo'^Key: ' a Full Data Package Reduced Deliverables Package Electronic Data Deliverables O M Hsl^ that apply) w s a H UST NPDES MIPP RCRA Stormwater DEP (PWS# ) Type (P=fTastic. G=GIbss, M H w > SAMPLE DESCRIPTION Final Air Volumi Matrix Type Sampling Info Cwfyhtar Volume (Liter, ate) o S ' I (ID must match container labels) (L *eFSBtte) Date Time Number of Crrntainers 1» 1 AlA c7?/^ aZ 2 w M CJ G 3 H CO CL 4 NJ 5 O O 6 CO o a. 7 H 8 1\J 9 NJ O £ o fU 10 O o (1) Relinquished by: Dale Time [2} Received by: Date Time ll(3) Relinquished by; Date Time o O I o (4) Received by: Date Time ;&) Relinquished by: Dale Time j(6) Received at Lab: ^^^^Date^ Time o co c iC. □ Method of Delivery; UPS PAS Courier Client US Mail Other NJ

NYC-WTC_000177735