Chain of custody form, PSC Analytical Services

NYC 9/11 Public Portal Document rv3</ zAiidiyiivai

4418 Pottsville Pike PSC Work Order#

CD Reading. PA 19605 phone: (610) 921-8833 CHAIN OF CUSTODY Page k Of i a. fax: (610) 921-9667 or 921-8407 PO# Quote #

Report Name,r^ r, k Q V\. yv._________________________ -'OB ID; Company MSoCa-CctL-. Results Mailing Address <£r tU 5 /e)7L ANALYSIS REQUESTED To: Slate yi// Use anachments if necessary. CD Telephone 3 . 3(1 C Please specify method requirements. Preservatives Key; CD tn Name A = Ascorbic Acid I w Company G CM Submit C = HC1 N2 = NaS2O3 co tn Mailing Address H = HNO3 S = H2SO4 G M o I Invoice city state ZIP I = Ice Z = ZnAcetate O H CD To; Telephone # Fax# N = NaOH X = Norte H Nil Credit Card Info (include exp. date) O no 03 O H M O O ^mpieTbyF^_____________ Due Date: (Rush TAT requires Lab approval) REPORTING REQUIREMENTS (Circle all that apply) I .X O = Other;

Preservatives (See above Key: H Hl < M O S G Hl Full Data Package Reduced Deliverables Package Electronic Data Deliverables BsiaBt/yat apply) _ I a UST NPDES MIPP RCRA Stormwater DEP (PWS# ) Type (P=PlaslK, G=Glass, A^Aw) O M 03 S SAMPLE DESCRIPTION Final Air Volumi Matrix Type Sampling Info Container Volume (Liter, elc) a M 03 H HI > I (ID must match container labels) (L oeearim) Date Time Number ot Containers S ' * I /JI.O o 2 IA.0^^ LcifUy .3 fLjv w 4 M CJ nj cn 5 H 0. 6

O O CO B. g o tn n 9 H K M- 10 I to O

I o tv □ (1) Relinquished by:

(4) Received by; Date

Dale Time

Time (2) Received by:

(5) Relinquished by: □ate

□ate Time

Time (3) Relinquished by:

(6) Received at Lab: > bate

, Date Time

Time o _______________ . 7>' I o o c MethocJ of Delivery; UPS FED-EX PAS Courier Client US Mail Other cn □ o o cn co

NYC-WTC_000178020