NCD980602163_19830513_Warren County PCB Landfill_SERB C_Resampling-OCR

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Location of Sampling:
Solid & Hazardous Waste Management Branch
Division of Health Services
N.C. Departmertt of Human Resources
P.O. Box 2091, Raleigh, N.C. 27602
CHAIN OF CUSTODY RECORD
Hazardous Waste Materials
Generator __ Transporter __ Treatment Facility
__ Storage Facility __ Disposal Facility Landfill
Other: _______ ..;,_ ______ ...;._. __ ___,___, ________ _
Company's Name -~f_C___.,[3.._ __ L/tl __ lJ_'D ___ J-_i _t _L __________ Telephone ( __ ) ______ _
Address _____ U)_-~,4 .... &~1..-.C~"-1---G,_..., ______ -'--_________________ _
number · street ,:..::.c.~,,.. 0 city state zip
Collector's Name _..._T.........,g"-__.__J.-~-=-:--·_L_._~___.<E-.1,~""'"-:;_·--'----Telephone (!!J.!L) 7J1 -l.171$
signature
Date Sample ---'-"---S"'--'-/_,-=g'-'-/ .... 8: .. ·...aJ"---~~------Time Sampled __ ~_M ________ hours
Type o_f _Pr_o_cess Generating Waste -:----'-----------------'---------
Field Information {sketch sampling location on back)
Field Sample -No. U1U J tJ
Chain ~f ~~=ion __ , /)
1. J~ (~.
2-~~ : signature
3.
signature
Results Reported
signature
title inclusive dates
title date