DOC032918-03292018142526

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Page / of
Samples Submitted to.
(-)-eentmi-Cab Raletgh ( ).Asheville RegienaFLab--SSwannanoa
Purpose / Investigation:
Sample Collector /
Forms Completed by
print NameI—Signarturbr-
(when of. lV'eeNe):
Lab Use Only
Lab Sample No.
Location Code
or Tag Number
Location Description
Date
Collected
Time
Collected
Number of
Sample
Containers
0190 100
004 /
N4e/NA�IaNnI ?Aper
a3w/lt
Don 6 UG 93
U(r.rNS Wick ep /Vr./
3 1 /il
111`7
�PN meter Co
1 /$
rv4$
nep $79
CFPLAq
031211/0
: 2<4
a
Rehorpu shed by:
(signature):
Date
rteGngwshed
Time
Relinquished
Received by:
(stgnafure):
Dale Received
lime Received
7c
3U rf
Method of Shipment (circle one):
State Couper Hand -Delivered
oral ExE�es _� UPS
Olner.
Shipment Container Sealed By:
(signetwe)
.. 5ocurlty Tape Broken By: .
fsgnatuie)
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 -4/7i/2016

Chain of Custody (COC) Record - Water Samples Page of 1
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Revised: 4/12/2016