DOC032218-03222018150811

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page I of /4
Samples Submitted to:
(-yeentrattarl7-Rateigti ( )Asheville Regienal-1 ab--Svvannanoa
t jaq Lqi3
14 eas rP.4
Purpose / Investigation:
G
Sample Collector!
Forms Completed by:
Print Name
ignatur
Field Storage conditions & location
(when al'otahle):
.
Lab Use Only
Lab Sample No.
Location Code
or Tag Number
Location Description
Date
Collected
Time
Collected
Number of
Sample
Containers
CO 64q
V4e("ArAiJf?^7arv<) er
22
`f
' SA
d
Oct 6as'
l3ruNsw;�k Cu vw
z ,
'7
a
a 6'u7, wive
066 70. /
�e.0 �rr Ce
�g
t8l
y.2S,q-
ao�72
b 3
CFPuR
Relinquished by:
(signature):
Dale
Relinquished
Time
Relinquished
Received by:
(signature):
Date Received
Time Received
D
WA�
r
0
Method of Shipment (circle one):
Slate Couper Hand-Defiveretl
ederal Express%
UPS
Omer:
Shipment Container Sealed By:////y//�
(siena(we) _ir1.
Security Tape Broken By:
rvgnaNre)
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 4/17/2016

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page of I
Samples Submitted to:
-(--)-Centfa4-Lab-_Raleigh_—(--)-Asheville-Regionahtab
—Swannanea C104 L.Z
Purpose / Investigation:
Sample Collector/
Forms Completed by:
�; �� ,_
Print Name
Signature
Field Storage conditions & location
(:,,hen applicable)
Lab Use Only
Lab Sample No.
Location Code
or Tag Number
Location Description
Date
Collected
Time
Collected
Number of
Sample
Containers
(:fPZ-1wov/:r ow-r.a)a c(,�,
31aD,/lP
/G -s- 7
a
V Pt S 0o C-'7
o&7r
130
%
V"alf7 0077
urea
Relinquished by:
(signature):
Date
Relinquished
Time
Relinquished
Received by:
(signature):
Dale Received
Time Received
Method of Shipment (circle one):
State Courier Hand -Delivered
Federal Express-
UPS
Other:
Shipment Container Sealed By:
(si9nalureJ
Secu rity Tape Broken By:.
(sgnaturel
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
Atmsed:4/12/2016