DOC030918-03092018155638

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
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Samples Submitted to:
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Purpose / Investigation:
Sample Collector
Forms Completed by:
PrnrName
signature
Field Storage conditions & location
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Lab Use Only
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Location Code
or Tag Number
Location Description
Date
Collected
Time
Collected
Number of
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Date Received
Time Received
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Slate Courier
Hand-DeliveredFederal
Ex rens UPS
Other.
Shipment Container Sealed By:
(signature)
Security Tape Broken By:
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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

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Chain of Custody (COC) Record - Water Samples Page of
North Carolina Division of Water Resources -Water Sciences Section Chemistry Laboratories
Samples Submitted to. ( 4_9 , h ( ) a - noa F- /� Ad
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Location Code
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Location Description
Date
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Time
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Container / Secunty Tape Comments:
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

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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 I
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Purpose / Investigation:
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Field Storage conditions & location
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Lab Sample No.
Location Code
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Location Description
Date
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Time
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Number of
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Shipment Container Sealed By:
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Container I Security Tape Comments:
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

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page of
Samples Submitted to:
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Location Code
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Date
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Time
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Container/ Secunty 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
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Revised_ 4/12/2016

Chain of Custody (COC) Record - Water Samples Page / of
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
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Purpose / Investigation:
Sample Collector/ Cl�i Y�P
Forms Completed by: Print Name' 1 Signature'
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Lab. Use Only - Number of
Location Code Date Time Sample
Lab Sample No. or Tag Number Location Description Collected Collected Containers
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Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page of
Samples Submitted to:
Ir}6efltraltab-Raleicdh--{-�4&;e1v+e-RsT�waa
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4613 GA
Purpose / Investigation:
Sample Collector/
Forms Completed by:
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Print Name
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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
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Time Received
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State Courier Hand -Delivered
Federal Express
UPS
Other:
Shipment Container Sealed By: -
(signaNre)
Security Tape Broken By:
(ygnatiae)
Container / Security Tape Comments:
Intra -Laboratory Chain of Custody - Lab Use Only
Lab Sample, Numbers
Starting with Ending with -
Number of Analyses
Bottles Requested
Relinquished
By:..
Received
By: Date _. Time.
Revised: 3/12/2016

Chain of Custody (COC) Record - Water Samples Page of
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Samples Submitted to: a&04 4.5 14e, . 6,4
Purpose / Investigation:
Sample Collector/
Forms Completed by: a ! ���G ✓t
Field Storage conditions & location
Number of
Location Code Date Time Sample
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Container/ Security Tape Comments:
vi5ed: 4/12/2016
UPS Other.

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page of
Samples Submitted to: ).Asheville-Regiena ^ ^noa t -P4 L.413 /-!/•Ae,us A
Purpose / Investigation: C tom, r-
SampleCollector / oM
Forms Completed by: Doer at
Print Name Ignatur
Field Storage conditions & location
/when arya'icable):
Lab Use On/y.;
Leb-Sample No
Location Code
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Date
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Time
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Revised: 4/12/2016

Chain of Custody (COC) Record - Water Samples Page of
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Samples Submitted to: j -j-Genual_ ab - Rale9h � I _CPA llfl14
L<.5 e, C r
Purpose / Investigation:
Sample Collector/ /�
Forms Completed by:4
Field Storage conditions & location
Number of
Location Code Date Time Sample
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7'f C UOG/1. t
Date
Time
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Dale
Time Received I
Method of Shipment (circle one): State Courier Hand -Delivered Federal Express j UPS Other:
Shipment Container Sealedw. P
(signature) - RY r
Container / Security Tape Comments:
Revised: 4/12/2016

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources -Water Sciences Section Chemistry Laboratories
Page / of
Samples Submitted to:
(-}eent Mut—Fta"h ( pshaville-RegienaPLab-Swaananoa
--PA I -A13
A Aenrs A
Purpose / Investigation:
G<
Sample Collector /
Forms Completed by:
print Name
tgnatur
Field Storage conditions & location
(x'hen appp2aD;eJ:
Cab Use Only -
,.
:Lab Sample No.
Location Code
or Tag Number
Location Description
gate
Collected
Time
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Number of
Sample
Containers
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Time
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Time Received
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Method of Shipment (circle one):
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Other:
Shipment Container Sealed By;
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Security Tapa.Broken By:
(ag .B.;.
Container/Security Tape Comments:
Intra-Laboratory,Chain of Custody - Lab Use Only.
Lab Sample Numbers
Starting with: Ending with
Number of Analyses
Bottles Requested
Relinquished
By:
Received
,By: Date Time
Revised: 4/12/2016