Chain of custody form for analytical services, Oct 2001

NYC 9/11 Public Portal Document

Chain of Custody Record Sample Container Information 4418 Pottsville Pike Reading, PA 19605 Bottle Type __ i phone: (610) 921-8833 fax: (610) 921-9667 ( G P IH ) *—y 6? ANALYTICAL SERVICES if of Containers “ Ipo # Preserved? (Y/N) C=> ^ssBs^^sssssss^^sss^^ss^ssss^^ssssssssssssssssssSssssasssslssssssss 7 Namo

Report Crsmpany JPc . Results Mailing Address Q Z/. To:

w G Cd Name Telephone If G M O H Send Company Dept.

H Mailing Address-^ /7 / O Invoice G %l To; Ci tv State ZIP Xfpage / _ of _ / O Credit Card # Exp. Date H PAS Quote# M O O H O Sampled AlFAtofc-ffc Matrix Date Time H S SAMPLE DESCRIPTION Type Sampled Sampled S 3 2' Cominenls/Hazards/ Location Details a o 73 M S I rcA- f .2' 1^^, en-kunes. :pvi . ( a H 2 M HI PCf^~ ?. /Dc^'ci^K 73 > 2^ 1/ 3 x’/er-’-M ■) G ' O 4 2:^0 _ to 5

CO 6 1/ ~ oi Pl 7 If ,)C Q. 8 N> 9 O (/(?C - c? O CO 10 I Q Special Instructions (including Data Deliverables and Turp Around Time); H (Mclvicff job Ph <7>7 7r^ rejn2/t//Ac4T)4< K I Time Samples Relinquished by: Samples Relinquished to; I Dale I Time I So Samples received by: ' I Date Time Samples Relinquished by; Samples Relinquished to I Date I Time I—i I Laboratory: o I o Method of Shipment/Delivery; UPS PA{S Courier Client dropoff Otner o o Samples Rec'd. on Ice? ( Y N n/a) Temp. Blank Sample Temp. Noles : co Samples rec’d intact?(Y N ) Custody seals intact?! Y N n/a ) ID on samples match C0C?( Y N ) (JI co VOC Samples have zero headspace?) Y N n/a ) Samples properly preserved? ( Y N n/a | o

NYC-WTC_000179291