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LABORATORY WESTCHESTER COUNTY
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o NAME ADDRESS VALHALLA, NEW YORK CT
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o CONTACT CONTACT _________________________ o'
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co SAMPLING ANALYSES o
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SAMPLE NO. SAMPLE NO. DATE TIME TYPE VOA BNA PCB METALS CN VATION (SPECIAL INSTRUCTIONS, CAUTIONS. ETC J O
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I. SAMPLED AND RELINQ. BY I. RECEIVED BY: ANALYSES/COMMENTS: IV, RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS.
SIGN: n SIGN: SIGN: SIGN:
PRINT: PRINT: PRINT: PRINT:
FIRM: FIRM: FIRM: FIRM:
DATE: IO.2S-O1TIME: DATE: TIME: DATE: TIME: DATE: TIME:
II. RELINQUI: BY: II. RECEIVED^: ANALYSES/COMMENTS: V. RELINQUISHED BY: V. RECEIVED BY: ANALYSES/COMMENTS:
SIGN: ( ‘-Va. SIGN:<=^6^— SIGN: SIGN:
PRINT: PRINT: PRINT:
FIRM: 4.^ FIRM: FIRM:
time: (^->7 DAT&z^^^TIME/^--^; DATE: TIME: DATE: TIME:
111. RELINQUISHED By:. ANALYSES/COMMENTS: VI. RELINQUISHED BY: VI. RECEIVED BY: ANALYSES/COMMENTS:
SIGN: SIGN:
PRINT: PRINT: PRINT:
FIRM: FIRM: FIRM: FIRM:
l<l^» (TIMEte-.V5 DATE: TIME: DATE: TIME:
EVIDENCE SAMPLES TAMPERED WITH:____ NO YES N/A SAMPLES DISPOSED OF ON:
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IF YES EXPLAIN IN REMARKS BY:
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