Chain of custody form for laboratory samples, Westchester County Lab

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I SDG#^; gABORATORY\' WESTCHESTER COUNTY ... “0 c CT

I NAME^ ‘ KJ ADDRESS;^^ .; VALHALLA. NEW YORK ‘ o' CONTACP-^ • ' ___________ "0 cont^ctH^ o -SAMPLING r-‘ -ANALYSES _______ ■? 9L LABORATORY SAMPLE^’'W M 5 IpeSt/ #OF PRESER- cOmMents ; O o SAMPLE NO. SAMPLE NO. DATE TIME TYPE y-T-’ ’ VOA BNA PCB METALS CN BOTTLES VATION (SPEQAL INSTRUCTIONS. CAUTIONS, ETC) s O ; C F 3 3 / /z6 /pz : 3

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r I, SAMPLED^D RELINQ. BY I. RECELVEp BY: ANALYSES/COMMENTS: IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS: SIGN^ — SIGN;45ttttH, PRINT:T <o PRINT: iW ri , SIGN: PRINT: SIGN: PRINT: FIRM:P«S^-^‘^,‘^ aa FIRM: FIRM: FIRM: DATE:'I-TlME;'l Si DATE:,/^^^ TIME:^iSs DATE; TIME: DATE; L 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: -i j.i « - (»y FIRM: FIRM: FIRM: FIRM; DATE: • -^IME: DATE: TIME: > -15^ ■ DATE: TIME: DATE: TIME:

VI. RELINQUISHED BY:

i III. RELINQUISHED BY: III. RECEIVED BY: ANALYSES/COMMENTS: 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//V^,;

IF YES EXPLAIN IN REMARKS > -7? SAMPLES DISPOSED OF ON:

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