DOC031518-03152018152006

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page f of
Samples Submitted to. (-reenWJrLab-Raleigh ( ).Ashaville-Regienal-1,8 SWaonanoa 1114 1-4i3 41J,ews A
Purpose/Investigation G�
Sample Collector/
Forms Completed by: print Name Ignatur
Field Storage conditions & location
(when appb�ah.'e).
Lab Use Only
Lab Sample No.
Location Code
of Tag Number
Location Description
Date
Collected
Time
Collected
Number of
Sample
Containers
'
000�a
o(n a3
ru NA 0 ( �A gof
/Is-// B
�♦r'
v •l%�
d
-:
UO Ga4
00
/ r"SwiGh Co /VI✓
o3 lyfl
//��
2' 36
a
oS25' eoJ Z4
a
Q
Pe.uoeer Ce
os ,r /e
g.'
Lf
oo S13
CFPLA A
3f,ylr9
;?lis
a
Relinquished by
(signalore).
Dale
Relinquished
Time
Relinquished
Received by:
Date Received
Time Received
G
G3 s !g
�'3o P
/(signature):
%ice Q
31Z—V
'7,'1 (-,oOh
Method of of Shipment (circle one): State Courier Hand -Delivered rFederal Express ) DPS OlheC
Shipment Container Sealed B; __..
Noralam)
Security Tape Broken By: .
fsgna(ure)
Container / 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 -411]/2015

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page I of �/
Revised: 4/12/2016

Chain of Custody (COC) Record - Water Samples Page of
North Carolina Division of Water Resources -Water Sciences Section Chemistry Laboratories
Relinquished by: Date I Time Received by
(signature): Relinquished Relinquished (signature): Date Received Time Received
0L 3//�-//gI -Yvs-'o„ .
Method of Shipment (circle one): Slate Courier Hand -Delivered ederal F�re,, UPS Other
—ContShipment Container Sealed BY: [ a War" -
Container/
ainer/ Security Tape Comments: -
evlsed:4/12/2016
Samples Submitted to:
( ) Central Lab- Raleigh (
) Asheville Regional Lab- Swannanoa
Purpose / Investigation:
Sample Collector/
P
�h /
Forms Completed by:
,_ -
Field Storage conditions & location
OR
(when app(cahle):
- _
Number of
Location Code
Date
Time
Sample
or Tag Number
Location Description
Collected
Collected
Containers
DKur
3 r
a
la
3
Cilemows adrall /10a
3
0!301,)
Relinquished by: Date I Time Received by
(signature): Relinquished Relinquished (signature): Date Received Time Received
0L 3//�-//gI -Yvs-'o„ .
Method of Shipment (circle one): Slate Courier Hand -Delivered ederal F�re,, UPS Other
—ContShipment Container Sealed BY: [ a War" -
Container/
ainer/ Security Tape Comments: -
evlsed:4/12/2016