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z WESTCHESTER COUNTY DEPARTMENT
O^tABS'k RESEARCH
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SDG# LABORATORY WESTCHESTER COUNTY
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NAME
CONTACT
ADDRESS
CONTACT
VALHALLA, NEW YORK
_________________________
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LABORATORY
sample.no. SAMPLE NO. DATE
SAMPLING
TIME'
SAMPLE
TYPE VOA BNA
rtST/
PCB
ANALYSES
METALS CN
# OF
BOTTLES
PRESER^
VATION
COMMENTS 7
(SPECIAL INSTRUCTIONS. CAUTIONS, ETC j
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3 ■ <7730
01- ±3^
ZdSst? 01- ^732^
3/3-Z^/o2- ^733_
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I. SAMPLED AND RI .INQ. BY I. RECEIVED BY; ANALYSES/COMMENTS: IV. RELINQUISHED. BY: . IV. RECEIVED BY; ANALYSES/COMMENTS;
SIGN:^/ij’^%7v> SIGN; SIGN:
PRINT-.S^^ PRINT: PRINT; PRINT:
FtRM;5(?/^ /^.FIRM; FIRM; FIRM:
DATE;(57‘z^?Z TIME; 333/ timeTmit'" DATE; TIME; DATE; TIME;
II. RELINQUISHED BY: 11. 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: Ilk 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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