DEQ-CFW_00069986

Report to: �. 1(Y\ re , Y+
SURFACE WATER SECTION
Page_ of
CHAIN OF CUSTODY (COC) RECORD
NC DENR/DWR LABORATORY (cheek one): CENTRAL 1 1 ARO
For Investigation of: V C
Sample collector (print name) !
and DM -I forms completed by: /�/'ba? <�i' !Z__
Sample collector's signature: LG
Field storage conditions and location (when applicable):
Lab Use Only
LAB NO.
STATION NO.
STATION LOCATION
DATE
SAMPLED
TIME
SAMPLED
NUMBER
OF
CONTAINERS
COLC
- hGt
77 --90 /7
09,60
l
7-do 1
1 0
�
7X-E,
070
i7f,
0
0912
7A
Z G rb10 5 tl)�K
W LP 0
0
) /3 --1, I 0�(
7:1) l7
.7
Relinquished by (signature): /
Date
•7-X / 7
Time
/51.
Rece v by (signature) c
Date
? -Z ("-n
Time
0710
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):
tate Courier Hand -delivered Federal Express UPS
Other:
Security Type and Conditions:
Seal
r
Broken y: -)(a (! {.�
-A.t , 1
�� �LGX v / Uv 6 .•' '
IlV 1 I(ALHD V1�Fi 1 Vim i �-i�ii
LAB NUMBERS
FROM THROUGH
va• �.vv a vv
NUMBER
BOTTLES
. - ......�.- .-.
ANALYSES
REQUESTED
RELINQUISHED
BY:
RECEIVED
BY:
DATE
TIME
QA\Fonns\Sample Receiving\COC form WR
4/10/0ldbs Revised: 8/23/2013 ntg
DEQ-CFW 00069986