Chain of custody form, NYC DEP sample AE05031, Mar 2002

z Z o o g WESTCHESTER COUNTY DEPARTMENT CHAIN OF CUSTODY RECORD co PAGE OF OF LABS & RESEARCH o . I “0 o SDG# LABORATORY WESTCHESTER COUNTY c o CT o ADDRESS VALHALLA. NEW YORK o NAME o' o CONTACT _3Z^~SSl2___ CONTACT _________________________ "0 o ro SAMPLING ANALYSES ro 9L LABORATORY SAMPLE PEST/ #OF PRESER- COMMENTS DATE TIME TYPE VOA BNA PCB METALS CN BOTTLES VATION O SAMPLE NO. SAMPLE NO. (SPECIAL INSTRUCTIONS. CAUTIONS. ETC.) o n4>J I g ^03 I TJOt =5 zm o c 3 CD 3

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I. SftMPIJn Aibl&RElJNQ. BY I. RECEIVED BY: ANALYSES/COMMENTS; IV. RELINQUISHED^ BY: IV. RECEIVED BY: ANALYSES/COMMENTS: SIGN: SIGN:-<—75 , SIGN; SIGN: PRINT:Sicpha.ni-^4 PRINT: PRINT; PRINT: FiRM:i^yCTi£'P FIRM; LV.A FIRM: FIRM: DATE:3jiyP3~ TIMEZV^ DATE:^/,/c;t^TIME;/^-c3c 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: