Chain of custody form, Sep 2001

<j • — __________ ______ ________ _ —-— 2 < P WESTCHESYER COUNTY DEPARTMENT CHAIN OF CUSTODGECORD PAGE 1 OF o 3o OF LABS & RESEARCH CD — I 0 o o SDG# _ LABORATORY WESTCHESTER COUNTY C O o o NAME MYCD67 —rasidolkesk ADDRESS VALHALLA, NEW YORK 258/01 - o' N CONTACT_______________ _ CONTACT "0 O. _________________ i o— O V SAMPLING ANALYSES _ COMMENTS f 0 SAMPLE PESTT #OF PRESER- R =■ DATE TIME TYPE 0 'VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS, CAUTIONS, ETC.) 00 O o 9h7/0/ /230 -ui 22— Del ddnukil% 2252 Q C

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SAMPLED 1.SIGN- AND RELINQ/ Y LRECE DBY: ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS: — eeeoxd)], taIGN: SIGN < : : . SIGN- PRINTSJephae JR ‘PRINT: USM PRINT:;; PRINT: FIRM: Mc DeP WaCSJwprirkiv: LhL - IRM: u FIRM: . FIRM: DATE:9//3/0/ TIME: 9284 DATE:^ (8/01TIME:Q*S DATE: TIME: DATE: TIME: 0

11. RELINQUISHED BY: 11. RECEIVED BY: ANALYSES/COMMENTS: V. RELINQUISHED BY: V. RECEIVED BY: ANALYSES/COMMENTS: SIGN: SIGN: SIGN: X: PRINT: PRINT: PRINT: FIRM: sn P' - TIME:

111. RELINQUISHED BY: FIRM: DATE­ TIME:

III. RECEIVED BY: ANALYSES/COMMENTS: DATE: TIME:

VI. RELINQUISHED BY: FIRM- DATE: TIME:

VI. RECEIVED BY: ANALYSES/COMMENTS: m 9 0900 00 SIGN:. 0 SIGN: SIGN: SIGN: PRINT: PRINT: PRINT: PRINT: FIRM: “ FIRM: FIRM: FIRM: DATE: TIME: DATE: TIME- I'- TIME: DATE: TIME:

EVIDENCE SAMPLES TAMPERED WITH:NO YES N/A SAMPLES DISPOSED OF ON: i YES EXPLAIN IN REMARKS _______________ . . . . ■ BY: ■I I — 01 0