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Z WESTCHESTER COUNTY DEPARTMENT CHAIN OF CUSTODY RECORD U
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o NAME Rye D E- ADDRESS VALHALLA. NEW YORK
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SAMPLING ANALYSES 2
LABORATORY SAMPLE PEST/ #OF PRESER- COMMENTS 3
SAMPLE NO. SAMPLE NO. DATE TIME TYPE CD
00 VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS, CAUTIONS. ETC.)
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I. SAMPLED AND RELINQ. BY 1. RECE
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ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS:
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11. RELINQUISHED BY: II. RECEIVED BY: ANALYSES/COMMENTS: V. RELINQUISHED BY: V. RECEIVED BY: ANALYSES/COMMENTS:
1? SIGN: SIGN: SIGN: SIGN:
PRINT: PRINT: PRINT: PRINT:
FIRM: FIRM: FIRM: FIRM:
DATE: TIME: DATE: TIME: DATE: TIME: DATE: TIME:
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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:
ICE SAMPLES TAMPERED WITH: NO YES N/A SAMPLES DISPOSED OF ON:
KS BY:
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