NCD980602163_19821007_Warren County PCB Landfill_SERB C_Chain of Custody Record - Hazardous Waste Materials-OCR

' , So+id & Hazardous Waste Management 'Branch
Division of Health Services
N.C. Department of Human Resources
P.O. Box 2091, Raleigh, N.C. 27602
CHAIN OF CUSTODY RECORD
Hazardous Waste Materials
Location of Sampling: Generator Transporter __ Treatment Facility
__ Storage Facility Disposal Facility VLandfiil
Other:
Company's Name f C,(5 L/JM!>,fl l (. Telephone (_· __ ) _____ _
Address . t{/8/'lf &v Co.
number · street , .',,~, -·, ·
Collector's Name JL (_ ~
signature
Date Sample -='_o_l_Si~t_i_c ______ ~'--------Time Sa6pled __ f>_M-'-------hours
city state zip
Telephone (et/'f ) 7 33-er ?<g
'~.-· Type of Process Generating Waste ----''----------------------------
Field Information (sketch sampling location on back)
Field Sample No. If}
Chain .'.'.:_Possession. ~
1. uL C :J. ·
signature ·
r__.l~J\)~U·~t=-:V~b,__,,_¼w.:::::..... __ '.(o!s/22-16 /2.k c
title inclusive dates
Loi!~ 2. 10/7ff.2.
signature title itic1usive dates
3.
signature title inclusive cates
Results Reported
signature date
CoO1c.0J1vfl Tl .s
I (OO 60 N C/760 £
2 (0/ 70 N 'i760 £.
3 10 2io N 9760£
4t 6 (O O Go N qg 'lo£
s-(O l? O N '1i 'IO £
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