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SDG# LABORATORY WESTCHESTER COUNTY
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NAME
CONTACT
ADDRESS
CONTACT
VALHALLA, NEW YORK
_________________________
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CD LABORATORY
SAMPLING
SAMPLE PEST/
ANALYSES
¥OF PRESER- COMMENTS
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1
SAMPLE NO. SAMPLE NO. DATE TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION (SPEOAL INSTRUCTIONS, CAUTIONS, ETC)
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/35'S'D 7g 7d^
7g/^
34^15V S’ 115'4
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I. SAMPLEQ^D RELINQ. BY I. RECEIVED BY: ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY. ANALYSES/COMMENTS;
SIGN?-—' SIGNtz^^^^hZ/H^
SIGN: SIGN;
PRINT; V,TI<^A^ PRINT: 01 PRINT: PRINT;
DATE; ioX'o,TIME: DATE:/^-^//^TlME: //i^
FIRM: //» FIRM: FIRM:
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 EXPLjAir^iy EMARKS BY:
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