Chain-of-Custody Record for Environmental Samples

NYC 9/11 Public Portal Document

FSC 4418 Pottsville Pike Chain of Custody Record Reading, PA 19605 Bottle Type ZjT Samp/e Container Information Tl (D IT

UI phone: 1610! 921-8833 fax: j610) 921-3667 LG P IHJ ANALYTICAL SERVICES # of Containers CzO □ IpoT ro Preserved? (Y/N) C_> a Name ^c<vsz-<<) Q? K vt ui Report Company P olr □ UI Results Mailing Address & ^5 fU T! To; Stale

Fax # ■Q w tn G ro Nanie Telephone n G ro Depl. o Send Company □ H 01 Invoice Address H O t£ , To: City State ZIP ft 93 age of | ro Credit Card # Exp. Dato O o PAS Quote// tu H ro Sampled by: 4/ Ail Vol. (L o o Mallis Dote Time H O SAMPLE DESCRIPTION or Olin) Type Siimplcd Sampled (n H < S ro Coinincnts/HazartlsZ Location Details HI 1 ro H I ?lfk» |5t ^taer Lotitsw c a o ro O ro a 3 H 2 illY S-/SZ- r t/a/fU' SiOb^ III ro H 3 UI ro > ro 3 ' •I o 5 tn to 6 □ w to 7 ro M 93 H 8 CD tn 9 tn O O 10 CO O Special Instructions (including Data Deliverables and Turn Around Time): H Samples relinquished to Date I Time Samples Relinquished by; Samples Relinquished to: I Dale I Time shipper or courier by: I So Samples received by: Dale Time Samples Relinquished by: Samples Relinquished to Date Time o Mcthiid (if Shipnient/Delivery: ... I,, I- PAii Courier (Zlient drop off Other I Lnburatojv; CV kllTl<7r.l 4^/5 o TJ I o Samples Rec'd. on Ice? ( Y 'CJyn/al —■ Temp. Blank Sample Temp. Notes : o co Samples rec'd intact?jjY/J ) Custody seals intact?! Y N ) ID on samples match COC?ltj>N t Jia VOC Samples have zero headspace?! V N t^^/) Samples properly preserved? (YN ) Jia CO o

NYC-WTC_000177736