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WESTCF^^ER COUNTY DEPARTMENT CHAIN OF GUSTO RECORD
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io SDG# LABORATORY WESTCHESTER COUNTY
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o 7 ADDRESS VALHALLA, NEW YORK C
o NAME CT
o CONTACT CONTACT _________________________ o'
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o> LABORATORY SAMPLE PEST/ #OF PRESER Comments 03
SAMPLE NO. SAMPLE NO. DATE TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS. CAUTIONS. ETC.)
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I SAM^EQ/^^EVINQ. BY 1. RECEIVED BY: ANALYSES/COMMENTS; IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS:
SIGN: IM SIGNCL^^-yy-r SIGN: SIGN:
PRINT; PRINT:^./^, PRINT: PRINT:
7IRM; FIRM: FIRM:
DATE: voHlot TIME:t3^ DATE: 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:
111. RELINQUISHED BY: III. RECEIVED BY: ANALYSES/COM M ENTS: 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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