Chain of custody form, Westchester County Labs, Oct 2001

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o: WESTCHESTER COUNTY DEPARTMENT CHAIN OF CUSTODY RECORD PAGE OF II g OF LABS & RESEARCH

SDG# LABOFIATORY WESTCHESTER COUNTY o o o NAME 7 P.e . f ADDRESS VALHALUK, NEW YORK o CONTACT CONTACT _________________________ KJ SAMPLING ANALYSES LABORATORY SAMPLE PEST/ PRESER^ COMMENTS 6^les SAMPLE NO. SAMPLE NO. DATE TIME TYPE I VOA BNA PCB METALS CN VATION (SPECIAL INSTRUCTIONS, CAUTIONS, ETC )

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I I. SAMPLED. LINO. BY I. REC ANALYSES/COMMENTS: IV. RELINQUISHED. BY; IV. RECEIVED BY: ANALYSES/COMMENTS; 1 SIGN>--- SIGN; SIGN: SIGN; PRINT: V, TI<SlAO PRINT PRINT: PRINT: FIRM; P. B. FIRM: DATE: Io-12'0,TIME: U; fl) DATE:, —-w V. FIRM: DATE; "TIME: FIRM: DATE; TIME;

II. RELINQUISHED BY: II. RECEIVEI;D 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: