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JJEM AQUEOUS SAMPLE COLLECTION/LAB REPORT FORM (NC CERT 482)
Regulated by NCDENRIDWQ-Groundwater section
To assign test, label shaded area with sample type (C=composite; GTgrab)
CHAIN OF CUSTODY
LOCATION HAYNES WIRE
COUNTY HENDERSON
SPECIAL INFORMATION(S)
OUTFALL # t
OUTFALL #
Monthly
ID NO.
HWC T l8'I C)
1 4-
INITIAL TEMP
L_'I
�,4 � -
GRAB
sam le time
COMP start
sample time
COMP end
date/ time
777
i.
TEMP @RECEIPT:.} °C TEMP @RECEIPT: oC
NOTE: THE ABOVE TEMP INDICATES THE TEMP. NOTE: THE ABOVE TEMP INDICATES THE TEMP.
FOR ALL CONTAINER(S) WITHIN. FOR ALL CONTAINER(S) WITH''N,
AMMONIA SAMPLES PRESERVED WITH H,SO4, PH=<2.0 YES NO
AMMONIA SAMPLES NEUTRALIZED WITH Na2SO3, Cl=< 0.1 _' B( NO -
FECAL SAMPLES PRESERVED WITH Na2SO3, CI=< 0.1 YES NO
COLLECTED BY: f ' ' r
ALL SAMPLES COLLECTED AND P ESERVED AT TIME OF COLLECTION 1N PLASTIC CONTAINERS UNLESS NOTED OTHERWISE BY.,
RELINQUISHED BY
DATE I TIME
RECEIVED BY
SPLIT SAMPLE(5) INF
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By the above signature I certify that all information is accurate to the best of my knowledge,
COMMENTS