DEQ-CFW_00069975

Chain of Custody (COC) Record - Water Samples Page ( of
Ki-46 nivicinn of water Resources -Water Sciences Section Chemistry Laboratories
Samples Submitted to:
(�entral Lab - Raleigh ( ) Asheville Regional Lab- Swannanoa
Purpose / Investigation:
.
Sample Collector /
Forms Completed by:
Print Name
Signat e
Field Storage conditions & location
(when applicable):
Number of .
Lab Use Only
Location Code
Date
Time
Sample
Lab Sample No.
or Tag Number
Location Description
Collected
Collected
Containers
7-3 /-/ 7,
Relinquished by:
(signature):
Date
Relinquished
Time
Relinquished
Received by:
(signafu e):
Date Received
Time Received
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Revised: 4/12/2016
DEQ-CFW 00069975