Chain of custody form, PSC Analytical Services

NYC 9/11 Public Portal Document

PSC PSC Analytical Services 4418 Pottsville Pike ■bl u Reading, PA 19605 CHAIN OF CUSTODY * c a phone; (610) 921-8833 Page . I or j C fax: (610) 921-966? or 921-840? n PO# Quote # c n Report Name ■Sk yvv< JOB ID: a £3^ c Company &-re. iIliMn c/ttJtx, Xwc. Results Mailing Address4^ ft Jt-y-ex,*' ■ ft) jV ANALYSIS REQUESTED TI

To; City State _________ ZIP /<?g>/t7 Use attachments if necessary. Telephone/??. gT-&o Fax# . ’i'jyOL Please specify method requirements. Preservatives Key: a Name 03 A = Ascorbic Acid tn Submit Company C = HCI N2 = NaS2O3 o Mailing Address Ch A H = HNO3 S = H2SO4 Invoice City A o To: Telephone # Credit Card Into (include exp. date) Slate Fax# ZIP 4 I = Ice N = NaOH Z = ZnAcetate X = None o A Sampled by: ^i^gL rx. Sampling Location (Specify State):_____________ 0 = Other: w o o Due Date: (Rush TAT requires Lab approval) A O $ H S < REPORTING REQUIREMENTS (Circle all that apply) u Full Data Package Reduced Deliverables Package Electronic Data Deliverables Prsservatives (See above Key ' O M list all that apply) JX3 S O p] H H UST NPDES MIPP RCRA Stormwater DEP (PWS# ) Type (P^PIastic, G=Glass, A=Air) > SAMPLE DESCRIPTION Final Air Volumt Matrix Type Sampling Info 2 O

to " I I (ID must match container labels) (L Bf miiT^

I r Dale Time .^(>0 Container Volume (Liter, etc)

Number of Containers CT

2 c w I p] 3 ^'o /^Qa tr na rt H

ro 4 5 TTTc- - /SaK i U I

o CT 6 a co O H 8 K I 9 I—i s 10 o o (1) Relinquished by: Date Tiiae (2) Received by: Dale Time (3) Relinquished by: Date Time o TJ I Dale o (4) Received by: Dale Time (5) Relinquished by: Time (6) Received at 3 Time o cn c CD o Method of Delivery: UPS ED-EX PAS Courier Client US Mail Other o co

NYC-WTC_000178016