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I NAME ADDRESS _ VALHALLA. NEW YORK
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SAMPLING ANALYSES
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o SAMPLE NO. SAMPLE NO. dat^ TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS, CAUTIONS. ETC)
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I. SAMPI IQ. BY I. RECEIVED BY: ANALYSES/COMMENTS: IV. RELINQUISHED. BY; IV. RECEIVED BY; ANALYSES/COMMENTS;
SIGN; \ SIGN^—79 / SIGN; SIGN:
PRINT; T^rinT: PRINT: PRINT;
FIRM: /Uy. o-/)i9^-/<-cii.MiC FIRM: FIRM: FIRM;
DATE:,o^f/o^ TIME;y^^^lDATI^//. 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;
ill. 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;
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IF YES EXPLAIN IN REMARKS BY: I
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