Chain of custody form, Westchester County Labs

Z z PAGE ( O^ / <D WESTCHEq^ COUNTY DEPARTMENT CHAIN OF CUSTODYOECORD o OF LABS & “earch co

'I o. Os O‘ SDG#. NAME CONTACT LABORATORY ADDRESS CONTACT WESTCHESTER COUNTY VALHALLA. NEW YORK •' A ■D C CT

'-D • saMPLinIO ANALYSES o ; P. o LABORATORY SAMPLE PEST/ WOF PRESER- COMMENTS 91 o>.. SAMPLE NO. SAMPLE NO. DATE TIME. TYPE VOA BNA PCB METALS CN O BOTTLES VATION (SPECIAL INSTRUCTIONS. CAUTIONS. ETC ) o o c I of 3 CD

SIS Aa- AP 74-'Z-^3

( •=5-zZo S2r l0/z4 2^ -2^o^ t 4-D ' T^Zfo A-?) Z-to-l-Ofe

22212-21 / q5?MX AT> '2^-2^

1^.

I

I. SAMPLED^D RELINQ. BY ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS; SIGN;— SIGN: SIGN: PRINT: V, T)<SlA^ PRINT: PRINT: FIRM: FIRM: l/fTt-, FIRM: FIRM: (DATE:|o)^y|o| TIME:|[,'O^ DATE: O/ZS/flITIME: DATE: TIME: DATE: TIME;

II. RELINQUISHED BY: II. RECEIVED BY: ANALYSES/COMMENTS: V. RELINQUISHED BY: V. RECEIVED BY; ANALYSES/COMMENTS; li SIGN; SIGN; SIGN; SIGN: PRINT: PRINT: PRINT; PRINT: FIRM: FIRM; FIRM: FIRM: DATE; TIME: DATE: TllfE; 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: ▼