DEQ-CFW_00069987

Chain of Custody (COC) Record - Water Samples Page of <�_
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Samples Submitted to: (t Central Lab - Raleigh ( ) Asheville Regional Lab - Swannanoa
Purpose / Investigation: 66,)
Sample Collector
Forms Completed by: Print Name Signa ure
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
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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) : ale Courier Hand -Delivered Federal Express UPS Other.
Shipment Container Sealed By:
(signature) �
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Container/Security Tape Comments: ° (2 ,'5;�L,
Intra-Laboratory Chain of Custody - Lab Use Only
Lab Sample Numbers Number of Analyses Relinquished Received
Starting with: Ending with: Bottles Requested By: By: Date Time
Revised: 4/12/2016
7
DEQ-CFW 00069987

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page of
c
Samples Submitted to:
( 'Central Lab
- Raleigh ( ) Asheville Regional Lab - Swannanoa
Purpose / Investigation: e
Sample Collector /
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
Method of Shipment (circle one) :
8fate Cour
Hand -Delivered
Federal Express UPS
Other:
Shipment Container Sealed By:
(signature)
Security Tape Broken B
(signature)
'�;V✓ ""'�_�"L'o�
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 00069988