Chain of custody form, Westchester County Dept of Labs

z I I WESTCHESTER COUNTY DEPARTMENT OF LABS & RESEARCH CHAIN OF CUSTODY RECORD PAGE OF o co

o -0 SDG# _____ LABORATORY WESTCHESTER COUNTY c ■o NAME ADDRESS VALHALLA. NEW YORK o' Si s CONTACT CONTACT “0 o SAMPLING ANALYSES p. 03 LABORATORY SAMPLE PEST/ #OF PRESER- COMMENTS w o SAMPLE NO. SAMPLE NO. DATE TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS. CAUTIONS. ETC) o o I0 c 3 CD I o^'Z-47o> 7 n 3

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I. SAM^ED Ah^ RELINQ. BY I. RECEIVED BY: ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS: SIGN: SIGN«^(A-^z SIGN; SIGN; PRINT; PRINT.^/^72) PRINT: PRINT: FIRM:(Ki'^^-bF^F FIRM:<ir;^' FIRM; FIRM: DATE:|^^/o, TIME: DATE;^^^/^^ TIME^J^ 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 EXPLA^i^ REMARKS BY;