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o WESTCHESTER COUNTY DEPARTMENT o
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OF LABS & RESEARCH
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SDG# LABORATORY WESTCHESTER COUNTY ■D
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o NAME ADDRESS VALHALLA, NEW YORK CT
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o CONTACT bK <S-S____________ CONTACT _________________________ o'
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bO SAMPLING ANALYSES o
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oo LABORATORY SAMPLE PEST/ #OF PRESER COMMENTS 91
o SAMPLE NO. SAMPLE NO. DATE . TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS, CAUTIONS, ETC) O
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I. SAMPLED AND RELINQ, BY I, RECEIVED/dY; ) 7. ANALYSES/COMMENTS: IV. RELINQUISHED. BY; IV. RECEIVED BY: ANALYSES/COMMENTS:
SIGN: SIGN; SIGN; SIGN:
PRINT;p.vO. PRINT; PRINT:
FIRM: - <0 FIRM:^^^t . FIRM: FIRM:
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 EXPLAI^REMARKS BY:
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