Chain of custody form for analytical services

NYC 9/11 Public Portal Document

RSC PSC Analytical Services 4418 Pottsville Pike PSC Work Order# £ t

Reading, PA 19605 phone: (610) 921-8833 CHAIN OF CUSTODY Page Of ( 1 r fax; (610) 921-9667 or 921-8407 PO# Quote # ( t

Report ^lame__________ 77^*^__________________________ JOB ID: 4 Company______ ^3torktx/^ ( Roci life » \WWV«lhV^ Mailing Address S’ fL ANALYSIS REQUESTED To: O'V stale y /zz / <2 Use attachments if necessary. Telephone . g 2 26 Fax# ■75'/. 6 Please specify method requirements. Preservatives Key: c Name A = Ascorbic Acid ( Submit Company C = HCI N2 = NaS2O3 Mailing Address H = HNO3 S =H2SO4 Invoice city state ZIP 0 I = Ice 2 = ZnAcetate To: Telephone # Fax# N = NaOH X = None Credit Card Info (include exp date)

Sampled by: Sampling Location (Specify State): O = Other:

Due Date: (Rush TAT requires Lab approval) 5 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=Plastit:, G=Glass, A=Air)

2 SAMPLE DESCRIPTION Final Air Volume Matrix Type Sampling Info Container Volume (Liter, etc) u (ID must match container labels) (L SHemtn) Dale Time Number of Containers 1 r £< 77^ c IIP t 2 4^- ^675^-2-/77- t 3 fi/c - r 4 5 ( Q ( 6 c H K 7 I 8 s Q 9 I—i o 10 o I (2) Received by: o (1) Relinquished by: Dale Time Dale Time (3) Relinquished by; Da:e Time o "i (4) Received by: Date Time (5) Relinquished by: Date Time (6) Reived at. J3ale/ Time o t co

(JI Method of Delivery: UPS FED-E>^ PAS Courier Client US Mail Other

NYC-WTC_000185611