DEQ-CFW_00069973

Chain of Custody (COC) Record - Water Samples Page of <51-
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Samples Submitted to: (t Central Lab - Raleigh ( ) Asheville Regional Lab - Swannanoa
Purpose / Investigation: Gels
Sample Collector)
Forms Completed b : T�
P Y Print Name Signa u[e
Field Storage conditions & location
Lab Use Only
Lab Sample No.
Location Code
or Tag Number
Location Description
Date
Collected
Time
Collected
Number of
Sample
Containers
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3
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Relinquished by:
(signature):
D to
Relinquished
Time
Relinquished
Received by:
(signature):
Date Received
Time Received
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Method of Shipment (circle one) : at Courier' Hand -Delivered Federal Express UPS Other:
Shipment Container Sealed By:
(signature)f
Security Tape Broken B
_ (signature) gCioh..
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Revised: 4/12/2016
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DEQ-CFW 00069973

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page
of �—
Samples Submitted to:
( Central Lab - Raleigh ( ) Asheville Regional Lab - Swannanoa
Purpose / Investigation: Gen
Y
Sample Collector/pzt
Forms Completed by:
print Name
Sign re
Field Storage conditions & location
(when applicable):
Lab Use Only
Lab Sample No.
Location Code
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
%4/7
A3
Method of Shipment (circle one) :
ate Cour' Hand -Delivered Federal Express UPS
Other:
Shipment Container Sealed By:
(signature)
Security Tape Broken B
(signature)
�V✓""^^ �'�'^�
Container / Security Tape Comments: I
Intra-Laboratory Chain of Custody - Lab Use Only ,
Lab Sample Numbers
Starting with: Ending with:
Number of Analyses Relinquished ' Received
Bottles Requested By: By: Date
Time
Revised: 4/12/2016
DEQ-CFW 00069974