Chain of custody form for WTC samples

NYC 9/11 Public Portal Document

o STL EDISON 777 Nasv Durham Road o X Edison, New -Jersey 08817 CHAIN OF CUSTODY/ ANALYSIS REQUEST o Phone; 73ZJ 549-3900 f=ax; (732) 349-3879 j PAGB OF o Name (far report and invoice} Snrripiere Name (Printed )

P.O,# i state (Location of aitaj: NJiP NY:^ Othec j Reguiatory Program: AKilLVBBREcJgMEO t ENTERVraS-OWTO IKXCATS^USCT; Afldysb TiwiaroaraJ Tin, tABUb£ONVY 'A-e. erandanf Project No; City . Slate Rush Chafes ftsSwifiatf Fori de-/c 0,7^ <CX y>_______ y\J ~S^ 2 Week n 5 Job No; Pisons Fax ) Weekly’

Y?3 Wto J ( Mo. of. SampEe Sample Wentlficatior Date Time Matrix Cord. v3 v3 Numbers

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o ■ '■ ' -............... ............. . T . iti..szsasssssiis=. I LO Preservjtion Used; 1=!Ce, Z = HCI, 3 = i-ijS0,, 4 = HNO^ 5 = NaOH Sc^: 03 cC / h a = OBier , 7 = Ottier Wafer fj CM <£3 Special Instructions'^ C4 OXt j , 7yt 12 CO ilVMgjlYWKfiftG Wsier Msteis Ftoed (YesiNoj? CO ReilriquFshetJ by Company □ate/Time Cempany H [i)/y Y <^6J7~z /4}-32-kJj 1 ex, ro oC Relinquished by Company c^te/Time Received by. Company S. Q O

CO 2) 2}________ i 7 o Relfnriuishad by Company Dale / Tims Received by Con^any O: CM O I o o o CM 3) t 2_ cn CO Relinquished by Comply Date / Time Recoivad by I Company o OJ ro 4} 1 4t o

NYC-WTC_000182175