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WESTCH@ER COUNTY DEPARTMENT
OF LABS & RESEARCH
CHAIN OF CUSTODRECORD
PAGE 1 -
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o SDG# _ LABORATORY WESTCHESTER COUNTY "0
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o NAME UCDef ADDRESS VALHALLA. NEW YORK O
o CONTACT_________ __ CONTACT o'
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00 SAM PLinG ANALYSES o
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LABORATORY SAMPLE PESTI #OF PRESER- COmmenTs 0
SAMPLE NO. SAMPLE NO. DATE TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS, CAUTIONS. ETC.) O
o
Q
Bx3 23255 q/2] C
3
CD
6153 23251 9/2)
/3SO 28511/2320 WTUS)
WEEE-ire] 25524/23% 9/20
26582/232 2%/20 (0%l
28suSs4 > 9/20 724$
S12s0 2.35192327*/ 20 I1O7
41350- 419o 0294 44
I. SAMPLED RELINQ. BY I. RECEIVED BY: ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS:
SIGN====<>----- * SIGN:- ,( SIGN: SIGN:
PRINT: V , lleC2 PRINT6-/0a . PRINT: PRINT:
FIRM: 0.5,7. FIRM: 49 FIRM: FIRM:
DATE: 9/21o/TME:/@(o DATE:f/24/00 TIMH:48 DATE: TIME: DATE: TIME:
II. RELINQUISHED BY: II. RECEIVED BY: ANALYSES/COMMENTS: V. RELINQUISHED BY: V. RECEIVED BY: ANALYSES/COMMENTS:
SIGN: SIGN: SIGN: SIGN:
PRINT: PRINT: PRINT: PRINT:
FIRM: FIRM: FIRM: FIRM:
DATE: TIME: DATE: TIME:, DATE: TIME: DATE: TIME:
III. RELINQUISHED BY: III. RECEIVED BY: ANALYSES/COMMENTS: VI. RELINQUISHED BY: VI. RECEIVED BY: ANALYSES/COMMENTS:
SIGN: SIGN: SIGN: SIGN:
PRINT: PRINT: PRINT: PRINT:
FIRM: FIRM: FIRM: FIRM:
DATE: TIME: DATE: TIME: DATE: TIME: DATE: TIME:
EVIDENCE SAMPLES TAMPERED WITH: NO YES N/A SAMPLES DISPOSED OF ON:
IF YES EXPLAIN IN REMARKS BY:
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