Chain of custody form for analytical services

NYC 9/11 Public Portal Document

RSC PSC Analytical Services 4418 Pottsville Pike 3 01 t£

o Reading, PA 19605 phone:(610)921-8833 CHAIN OF CUSTODY Page ( of ( 00

□ ro fax: (610) 921-9667 or 921-8407 Quote # □ PO# ro Report Name Zp k'A JOB ID: aJCk O Company A-Sf & CAlck-tU rc Results Maiiing Address "0 [q (4 I h~- X I V— loyu -4^ ANALYSIS REQUESTED To; City State /lA / ZIP Use attachments if necessary. Telephone # |J^ , S. 2 Z 21 Please specify method requirements. Preservatives Key: tn Name $ A = Ascorbic Acid n Submit Company C = HCI N2 = NaS2O3 Mailing Address H = HNO3 S =H2SO4 Invoice City state ZIP 1 = Ice iZ = ZnAcetate To; Telephone # Fax# N = NaOH X = None Credit Card Info (include exp. date)

Sampled by: Sampling Location {Specify State): 0 = Other:

Due Date; _______ (Rush TAT requires Lab approval) REPORTING REQUIREMENTS (Circle all that apply) Full Data Package Reduced Deliverables Package Electronic Data Deliverables Preservatives (See above Key: list all that apply) UST NPDES MIPP RCRA Stormwater DEP (PWS# ) Type (P^PIastic, G=Gtass, A-Air)

SAMPLE DESCRIPTION Final Air Volumf Matrix Type Sampling Info Container Volume (Liter, etc)

(ID must match container labels) (L ojs»miny Date Time Number of Containers

It 4/'~^-^z5'^l-<T'/- 4yz~~ ZISZZ m

Q 2,- -rry - I tc ■Ar^- - 0^0(- jTY-Hfj 3 ________ IM

Ik Arc - - ->77 -

l"^ o H 5 6 I to s O 8 9 o o 10 I o o (1) Relinquished by: Time (2) Received by: Date lime (3) Relinquished bt Date Time co T o .(4) Received by: A/ ~~ Date Time (5) Relinquished by; Date Time (6) Received at t ab\ TZZ co ........ ......... ____ — C CO Method of Delivery: UPS z' FED-EX ) PAS Courier Client US Mail Other '_r

NYC-WTC_000185610