NYC-WTC_000214141

NYC 9/11 Public Portal Document

CHAIN-OF-CUSTODY / Analytical Request Document /^ceAnalyticar The Chaln-of-Cuatody te a LEGAL DOCUMENT. All relevant tielda muet be completed accurately. www.pacel>b<.cam Required Client Information: Report To: Section B I Page: y o1 | 625144 Required Client Information; Section A To Be Comploled by Pace Analytical and Ctenl SSCtion C Company Copy To; Quote Reforenc©: Client Information (Check quotafcontract): Address Invoice To; Requested Due Dale; 3^7 Project Manager;

P.O. * Turn arourKl times lees than 14 days subject to Project«: laboratory and contractual obUgations and may result in a Project Name: Rush Turnaround Surcharge. Profile »: H ^'33 Turn Around 'Rme (TAT) in calendar days. Phone |Fax ~7 Project Number Requested Analysis:

/WS=M?1 Section D Required Client information; Valid Matrix Codes ◄------- — Q PreservatIvBS MATRIX CODE WATER WT ISS SAMPLE ID SOIL SL 8 s12 ■gI OIL WIPE OL WP X ’I ..4> a: Olfsilh S One character per box. AIR AR UJ I- (A-Z,0-9/.-) Sample IDs MUST BE UNIQUE TISSUE TS I mm/dd/yy Remarks / Lab IC

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S SHIPMENT METHOD AIRBILL NO I SHIPPING DATE IS pJES! i s:-f E NO. OF coolers!,,’'/, „| RELINQUISHED BY /AFFILIATION j DATE TIME i ACCEPTED BY / AFFILIATION | DATE | TIME I

O 1—1 o SAMPLE CONDITION SAMPLE NOTES I o Temp in °C I o 121 o Received on Ice Y® CO

o Sealed Cooler I SAMPLER NAME AND SIGNATURE PRINT Name ot SAMPLER: o Samples Intact 1^ j’ SIGNATURE of SAMPLER: , I DATE Signed; (MM/DD/YY) Additional Comments: /, z? rv'T'

NYC-WTC_000214141