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WESTCHES-^COUNTY DEPARTMENT
OF LABS & RESDkRCH
CHAIN OF CUSTODY ^ORD PAGE ( O is
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SDG# LABORATORY WESTCHESTER COUNTY
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NAME
CONTACT
SAMPLING
ADDRESS
CONTACT
VALHALLA, NEWYORK-
____________________
ANALYSES
1
00
LABORATORY
SAMPLE NO. SAMPLE NO. DATE TIME
SAMPLE
TYPE VOA BNA
PEST/
PCB METALS CN
#OF
BdTTLES
PRESER-
VAT1ON
COMMENTS
(SPECIAL INSTRUCTIONS, CAUTIONS, ETC )
5
. 2^313
V
I ID/-2^ib
1
||?><rO infos' ±^3/7
37-^2-?- lx
^24 5T) 0^57-
, /
*7^ 2-ST? 5 2- ^^,224
I. SAMPI NCL«Y I. RECEIVED BY: ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS:
SIGN: SIGN-t3— / SIGN: SIGN:
PRINT: PRINT:^^yg7rz>zv<_ PRINT: PRINT:
........
FIRM: 3>EP FIRM:4^ FIRM: FIRM:
DATE: ic/jii/oi TIME: PATE:TIME:/^.. 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 EXPLAIN IN REMARKS BY:
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