Chain of custody form, NYC DEP sample AE04843, Feb 2002

■ z z WESTCHESTER COUNTY DEPARTMENT CHAIN OF CUSTODY RECORD o OF LABS & RESEARCH PAGE J OF__ L co

§ SDG# LABORATORY WESTCHESTER COUNTY “0 c '2 o. o NAME CONTACT ADDRESS CONTACT VALHALLA. NEW YORK ■ _________________________ CT o' o "0 sampling ANALYSES o cn LABORATORY SAMPLE PEST/ #OF pReser- 03 COMMENTS ro SAMPLE NO. SAMPLE NO. DATE TIME TYPE VOA SNA PCB METALS CN BOTTLES VATION (SPECIAL INSTRUCTIONS. CAUTIONS. ETC ) O o o c 3 3 <.l 1 1 o 3

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I. SAMI BYI. RECEIVED,BY,lYi, f. ____ LINQ. ANALYSES/COMMENTS; IV. RELINQUISHED. BY: IV. RECEIVED BY: ANALYSES/COMMENTS: siGr^ SIGN: SIGN; PRINT PRINT: PRINT: FIRM: FIRM: FIRM: DATEi<’'2^ DATE: TIME: DATE: TIME: II. RECE|\/e6 BY; ANALYSES/COMMENTS: V. RELINQUISHED BY: V. RECEIVED BY: ANALYSES/COMMENTS: II. RELINQUISHED BY: 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 B^: ANALYSES/COMMENTS: SIGN; SIGN; SIGN: SIGN; 1 PRINT: PRINT: PRINT: I PRINT: . FIRM; FIRM: - FIRM; DATE: TIME: FIRM; DATE; 1 TIME: DATE: TIME: DATE: TIME:

EVIDENCE SAMPLES TAMPERED WITH: NO YES N/A SAMPLES DISPOSED OF ON:

IF YES EXPLAIN IN REMARKS BY;