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WESTCHNWDER COUNTY DEPARTMENT
OF LABS & RESEARCH
CHAIN OF CUSTO RECORD — •7
PAGE / OF__ (
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1 SDG# S LABORATORY WESTCHESTER COUNTY
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NAME MVC. DEP -ensido Aosk ADDRESS VALHALLA, NEW YORK
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N CONTACT CONTACT ___________________ _____ "0
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o SAMPLING ---ANALYSES #OF PRESER- -------- COMMENTS—_ —
0
00 LABORATORY SAMPLE —pEW
SAMPLE NO. SAMPLE NO. DATE TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS, CAUTIONS, ETC)
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De l I 8 22. 52 9j/0) /236 •/ C
_60— 3
CD
Cay Lest—1 22754 A(1/o/
093
C LB 72-75 7//1/0/
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1. SAMPLED AND RELINQ, BY RECEIVED BY: ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS:
SIGN:&&/A*lAa GN __ SIGN: SIGN:
PRINTSphave JR PRINT/USMM . . 02/
PRINT:,. PRINT:
9/13/0 dePWSFIRM:
DATE MC,
FIRM: Lh l .‘S FIRM:
DATE! . ?
FIRM:
/ TIME: 92s DATE:a/:8/o/TIME:Q TIME: DATE: TIME:
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11. RELINQUISHED BY: 11. RECEIVED BY: ANALYSES/COMMENTS: V. RELINQUISHED BY: V. RECEIVED BY: ANALYSES/COMMENTS:
SIGN: SIGN: SIGN: SIGN-
:' ya , ee PRINT:
PRINT: 009555** PRINT: PRINT:
FIRM:
FIRM:
DATE: . TIME.
FIRM:
DATE: TIME: m nd FIRM:
DATE: TIME: DATE: TIME:
HI. RELINQUISHED BY; III. RECEIVED BY: VI. RELINQUISHED BY:
ANALYSES/COMMENTS: VI. RECEIVED BY: ANALYSES/COMMENTS:
SIGN:
—
SIGN: ( SIGN: SIGN:
PRINT: PRINT: PRINT: PRINT:
FIRM: m FIRM: FIRM: FIRM:
DATE: TIME DATE: TIME: DATE: TIME DATE: TIME:
tm
EVIDENCE SAMPLES TAMPERED WITH:____ NO_____ YES____ N/A 9 SAMPLES DISPOSED OF ON:_____________________
IF YES EXPLAIN IN REMARKS BY:
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