Chain of custody form, Westchester County Labs

z o WESTCHEs® county department CHAIN OF CUSTODY^ECORD o OF LABS & f^EARCH co PAGE OF g ■D SDG# . ............_________ _ LABORATORY WESTCHESTER COUNTY c o CT o NAME ADDRESS VALHALLA. NEW YORK o o' o CONTACT CONTACT _________________________ ■D O SAMPLING ANALYSES 3. CD LABORATORY SAMPLE 03 -p- PEST/ #OF PRESER- COMMENTS SAMPLE NO. SAMPLE NO. TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS. CAUTIONS. ETC ) o o o c 3 CD

I. SAMPl^D AND R£LWQ. BY I. RECEIVED BY: ANALYSES/COMMENTS: IV. RELINQUISHED. BY; IV. RECEIVED BY: ANALYSES/COMMENTS; SIGN; SIGN: SIGN: SIGN; PRINT;.SL4a>.^ , I J. ^fT PRINT; PRINT: PRINT; FIRM; FIRM; FIRM: FIRM; TIME: DATE; TIME: DATE: TIME: DATE: TIME:

II. RELINQUISHED BY;, II. REG- ANALYSES/COMMENTS: V. RELINQUISHED BY: V. RECEIVED BY: ANALYSES/COMMENTS: SIGN; signL SIGN: SIGN: PRINT: A.<,h PRINT:- PRINT; PRINT: FIRM: FIRM: ^^|TIME;//:6 FIRM: FIRM; DATE:/.^/^^^^ TlME;/a;zS5“T5ATE: 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;