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o IY DEPARTMENT CHAIN OF CUSTODY RECORD o
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o LABORATORY WESTCHESTER COUNTY “0
o ADDRESS VALHALLA, NEW YORK
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o NAME AJU CT
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CONTACT CONTACT _________________________
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SAMPLING ANALYSES o
o LjABORATORY SAMPLE PEST/ # OF PRESER COMMENTS 9L
SAMPLE NO. SAMPLE NO. DATE TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS. .CAUTIONS. ETC )
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7-/ ? 102. c
3
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3
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I. SAMF^D AND RELINQ. BY I. RECaVZD'.BY; ANALYSES/COMMENTS; IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS;
SIGN; SIGN; SIGN; SIGN:
PRINT; TT- PRINT;1^(M PRINT: PRINT;
FIRM; FIRM: OW FIRM; FIRM:
DATE: TIME:/?-^^ :i£) 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 EXPLAIN IN REMARKS BY:
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