DEQ-CFW_00069981

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page of 1
Samples Submitted to: ( ) Central Lab - Raleigh ( ) Asheville Regional Lab - Swannanoa
Purpose / Investigation:
Sample Collector /
Forms Completed by: hJu��t i9
P,Nn[ Name.' Slgrt�ture
Field Storage conditions & location
(when applicable) :
Number of
L,b use Only
Location Code Date Time Sample
Lab Sample No: ` or Tag Number Location Description Collected Collected Containers
157
LY
Relinquished by:
(signature):
Date
Relinquished
Time
Relinquished
Received by:
(signature):
Date Received
Time Received
h"7
Revised: 4/12/2016
DEQ-CFW 00069981

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Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page I of
Samples Submitted to:
( ) Central Lab - Raleigh ( ) Asheville Regional Lab -- Swannanoa
Purpose / Investigation: �en
CPF/vi o,4,4
d- Pic a Bloc/¢
Sample Collector
Forms Completed by:
X11z_ Al
Print Name
Signature
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
r
1/ 0,2
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Method of Shipment (circle one) :
State Courier
Nand -Delivered
Federal Express UPS
Other:
Shipment Container Sealed By:
(signature)
Security Tape Broken By:
(sAgnatun3)
Container / 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 00069982

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Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page / of l
Samples Submitted to: ( ) Central Lab - Raleigh ( ) Asheville Regional Lab - Swannanoa
Purpose / Investigation: GG'rt rf- /n 0 f T d
Sample Collector /
Forms Completed by: u��( �i^ n
Prinf Nerve: ` ` Signature
Field Storage conditions & location
(when applicable) :
Oh Use Only Number of
Location Code Date Time Sample
Ldb Sartp a No::`. or Tag Number Location Description Collected Collected Containers
Relinquished by:
Date
Time
Received by:
(signature):
Relinquished
Relinquished
(signature):
Date Received
Time Received
Revised: 4/12/2016
DEQ-CFW 00069983

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry laboratories
Page of
r
Samples Submitted to: { ) Central Lab - Raleigh { ) Asheville Regional Lab - Swannanoa
Purpose / Investigation:
Sample Collector) l I�, /JlG�
I
Forms Completed by: ` ` ' �1�z
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Field Storage conditions & location
(when applicable) :
LaicJse Eihly
Number of
Location Code
Date
Time
Sample
f�lxSirt Nn
' or Tag Number
Location Description
Collected
Collected
Containers
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Relinquished by:
Date
Time
Received by:
_ (signature):
Relinquished
Relinquished
(signature):
Date Received
Time Received
Method of Shipment (circle one) State Courier band -Delivered Federal Express UPS Other:
Shipment Container Scaled By:
geCd�ti�►�'��g��gn g� x �
(signature)
�
Container t Security Tape Comments:
S
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Revised: 4/12/2016
DEQ-CFW 00069984

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 L.ab - Swannanoa Y
Purpose / Investigation: efl k i X,f '_ �q 0 /)j l/j
Sample Collector /
Forms Completed by;
f?nnf iY8i7Ie - 5igftatuie
Field Storage conditions & location
(when applicable) :
Ilse Eyn�y
`
Number of
Location Code
Date
Time
Sample
? f15apf�iVo',
or Tag Number
Location Description
Collected
Collected
Containers
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Relinquished by:
Date
Time
Received by:
(signature):
Relinquished
Relinquished
(signature):
Date Received
Time Received
Method of Shipment (clrole one) : State Courier Hand -Delivered Federal Express UPS Other:
Shipment Container Sealed By:
g�urfl�i �3�8Mken gi'
(signature)
Container / Security Tape Comments:
RIP t
OR
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t
3 KA F 3> -;
t
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Revised: 4/12/2016
DEQ-CFW 00069985