Chain of custody form, PSC Analytical Services

NYC 9/11 Public Portal Document

RSC PSC Analytical Services 4418 Pottsville Pike PSeWork Order# a u Reading. PA 19605 CHAIN OF CUSTODY I n phone: (610) 921-8833 Page of Z T C fax: (610) 921-9667 or 921-8407 n PO#________ Quote# C Ci Report Name JOB ID: 4 Company Results Mailing Address /rre ~ /^scT^'Yct.'Tc^ ANALYSIS REQUESTED a To: Qty /\-V Stale ZIP Use attachments if necessary. w Telephone# '2-/2^'S’T-S,^ Fax# - — Please specify method requirements. Preservatives Key: 1 G Name CO A = Ascorbic Add 0 G r M O Submit Company o C = HCI N2 = NaS2O3 H Mailing Address H = HNO3 S =H2SO4 H Invoice City state ZIP Ci l = lce Z = ZnAcelate O To: Telephone# Fax# N = NaOH X = None hO 03 Credit Card Info (include exp. date) O H Sampled by: 2-<rV| Sampling Location (Specify State): O = Other: M O O Due Date: 7 (Rush TAT requires Lab approval) H O REPORTING REQUIREMENTS (Circle ail that apply) $ < G M H a Full Data Package Reduced Deliverables Package Electronic Data Deliverables Preservatives (See above Key; o H list all that apply) ?3 s a M H H UST NPDES MIPP RCRA Stemwater DEP (PWS# ) Type (P-Plastic, C=Glass, A=Alr) V >

S ' S SAMPLE DESCRIPTION Final Air Volume Matrix Type Sampling Info Container Volume (Liter, etc) O (L-0F-iflin) Date Number of Containers (ID must malcli container labels) I a w 7 1/ c I M h3 3 6CY2 u r\ H 4 yg6-/^7c. V / NO O 5 ^7 I (i O 6 0 CO 0 o H s 9 NO 10 S O I—i (1) Relinquished by£_^ Time (2) Received by: Date Time (3) Relinquished by; Date Time o o I ' Date Time (5) Relinquished by: Dale Time (6) Received al Lab:__ Date Time o (4) Received by: o On __________ cn o Method of Delivery: UPS FED-EX PAS Courier Client US Mail Other o

NYC-WTC_000178017