NYC-WTC_000208284

NYC 9/11 Public Portal Document

f=>sc A'/f/sAHCSAMPLING PSC Work Order #

Il- 4418 Pottsville Pike phone: (610) 921-8833 CHAIN OF CUSTODY Page ? of r /

Reading, PA 19605 lax; (610) 921-9667

PO# Quote # Name Name Company Q, Report Submit Company Mailing Address .......... Invoice Results Mailing Address / ix City Stale ZIP ID CO To; City state ZIP /.'y/p To; Telephone # Fax# 01 I Telephone # # Credit Card Info (include exp. date) A ,, . 01 I COMMON MATRIX TYPES Job/Project Name: □ I. Badge (OVM/Passive Monitor) 6. Wipe (specify type) Sampler's Name(s): CD 2. Tube (specify type: charcoal, siiica. XAD, etc) 7. TeiiJar Bag Sampling Location (Specify State); 3. Train (filter -r tube. 2 lubes in scries, etc) 8.Summa Can Due Date (Rush results requires Lab approval); 4. Hltcr/Cassette (siiccify PVC, MCE, UFF, etc.) 9. PUF/Resin/XAD REPORTING REQUIREMENTS (Circle all that apply): .5. Impinger Solutions (.specify components) 10, Other (list details): Full Data Package Reduced Deliverables Pkg Electronic Data Deliverables

FWAt ATR MATRIX MEDIA SAMPLE FLOW RATES sLd SAMPLE DESCRIPTION SAMPLE ANALYSIS REQUESTED (list catalog (spsetfyi- Lifers, DATE TIMES (specify units: (,see above ) Use attacliiiieins if necessary. (ID must match container labels) list) number) rninutes.-etc) Start Slop Initial Final Average Please specify method reqiiirenienls. 1 5xZZ2 7va 2 /CO C/Vi^ 3 4 ///A _Z£XCxJ_ V T' X v A U to 5 CL 6 7 Q H D. 8 K CD I CM 9

I o n □ OJ 10

(1) Relinquished by: Date, Time (2) Received by: Date Time o a I >•0 o o 00 co Time (4) Recced by: Time o (3) Relinquished by: Date Dale, NO Q_ 7 /ics Us-n I—i tC. 0) co cn cn Method of Delivery: UPS FED-EX PSC Courier Client US Mail other

NYC-WTC_000208284