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WESTCHESTER COUNTY DEPARTMENT
OF LABS & RESEARCH
CHAIN OF CUSTODY RECORD PAGE[ OFJ. co
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I SDG# LABORATORY WESTCHESTER COUNTY c
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o NAME ADDRESS VALHALLA. NEW YORK o'
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CONTACT CONTACT _________________________ o
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o sampling ANALYSES 9L
KJ LABORATORY SAMPLE PEst/ #OF PRESER- COMMENTS 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. SAMPI INQ. BY I. RECEIVED BY: ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS:
SIGN: SIGN; SIGN:
.............................
PRINT; PRINT: PRINT:
FIRM: 1> £P FIRM: . FIRM: FIRM:
DATE: lol 2D jo] TIME: /l,'P2A 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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