Chain of custody form, Westchester County Labs

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WESTCHESTER COUNTY DEPARTMENT CHAIN OF CUSTODY RECORD o co OF LABS & RESEARCH PAGE OF § s o o o SDG# NAME CONTACT ______________ LABORATORY WESTCHESTER COUNTY ADDRESS CONTACT VALHALLA, NEW YORK ________ ________________ ■D c CT o' "0 o SAMPLING ANALYSES 03 00 LABORATORY SAMPLE PEST/ # OF PRESER­ COMMENTS SAMPLE NO. SAMPLE NO. DATE TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS, CAUTIONS, ETC.) O o HZtLKIZZ 2/1 ~ ZZEH dglQ ~7~7 / , 10 o c 3 EIol ns |0 o 3

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I. SAMPLED AND RELINQ, BY I. REM ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY; ANALYSES/COMMENTS; SIGN: /• 1?^. SIGN:^ SIGN: SIGN: PRINT; PRINT: PRINT: PRINT: FIRM: hive FIRM: IzfY, FIRM: FIRM: DAT&n/^jol time:/S' DATEuHj)o|TIMEJ^ 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;

111. RELINQUISHED BY; 111. 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; f I IF YES EXPLAIN IN REMARKS BY;