DEQ-CFW_00025083

Report to: ! 1 Y1 �CL'. ," >7 SURFACE WATER SECTION
Page __j of
NC DENRIDWR LABORATORY (check one); WICENTRAL I I ARO
For Investigation of:
C- J i X
Sample collector (print name)
and DM 1 forms completed by:
_" /YJ
Sample collector's signature: _-------------
Field storage conditions and location (when applicable):
Lab Use Only
LAB NO.
STATION NO.
STATION LOCATION
DATE
SAMPLED
TIME
SAMPLED
NUMBER
OF
CONTAINERS
c
L_ C _ Gl J
77 �� /7
,
1
2
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- 7
118
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7 j9 17
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Relinquished by (signatwe): ' 1
Ala
Date
717
Time
1<5.
Rece v by (signature) c '�
Date
7-�r-c�
Time
o�10
Relinquished by (signature :
Date
Time
Re ved by (signature):
Date
Time
Relinquished by (signature):
Date
Time
Received by (signature):
Date
Time
Method of Shipment (circle one):
c tate Courier Hand -delivered Federal Express UPS
Other:
Security Type and Conditions:
Seal d,k:
Broken
INTRALABORATORY CHAIN OF CUSTODY - Lab Use Only
�,A
T/911t�
LAB NUMBERS
FROM THROUGH
NUMBER
BOTTLES
ANALYSES
REQUESTED
RELINQUISHED
BY:
RECEIVED
BY:
DATE
TIME
QA\Forms\Sample Receiving\COC form WR
4/10/01dbs Revised: 8/23/2013 ntg
DEQ-CFW 00025083