DEQ-CFW_00025091

Page of (31—
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Samples Submitted to:
(t Central Lab - Raleigh ( ) Asheville Regional Lab - Swannanoa
Purpose / Investigation: ��,�
Sample Collector /
Forms Completed by:
Print Name
Signa ure
Field Storage conditions & location
(when applicable):
Lab Use Only
Location Code
Lab Sample No. or Tag Number
Location Description
Date
Collected
Number of
Time Sample
Collected Containers
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Relinquished by:
(signature):
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D to Time
Relinquished Relinquished
Received by:
(signature):
Date Received
Time Received
-7-62-0
Method of Shipment (circle one) :
ate Courier' Hand -Delivered
Federal Express UPS
Other:
Shipment Container Sealed By:
(signature)
-
TSecurity
Tape Broken B '
(signature) dh
Container /Security Tape Commentse-k: 7
Intra-Laboratory Chain of Custody - Lab Use Only
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Lab Sample Numbers
Starting with: Ending with:
Number of Analyses
Bottles' Requested
Relinquished Received
By: By: Date Time
Revised: 4/12/2016
DEQ-CFW 00025091

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North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page C/ y c of 9---
Samples Submitted to:
( Central Lab
- Raleigh ( } Asheville Regional Lab - Swannanoa
Purpose / Investigation: M
Sample Collector /
Forms Completed by:
Print Name
sign re
Field Storage conditions & location
(when applicable).
Lab Use Only
Location Code
Lab Sample No. or Tag Number
Location Description
Date
Collected
Time
Collected
Number of
Sample
Containers
Relinquished by:
(signature):
Date
Relinquished
Time
Relinquished
Received by:
(signature):
Date Received
Time Received
%/7
Method of Shipment (circle one):
ate Cour
Hand -Delivered
Federal Express UPS
Other:
Shipment Container Sealed By:
(signature)
%
Security Tape Broken B :
(signature)
1
,I
Container i Security Tape Comments:
Intra-Laboratory Chain of Custody - Lab Use Only
Lab Sample Numbers
Starting with: Ending with:
Number of
Bottles <
Analyses
Requested
Relinquished Received
By: By: Date
Time
Revised: 4/12/2016
DEQ-CFW 00025092