DOC040918-04092018132821

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Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources -Water Sciences Section Chemistry Laboratories
Page II of
Samples Submitted to. (-}eamnal-ab—Raleigh ( jl�shearille-RegionaFLab--Swannanoa C �� y,.yy3 �-y yA pN5 i�
/InvestigationSample
Collector/ 1b`��Forms Completed by: Print NamerPurpose
d Storage conditions R location
(when a(M;icab'aj
Lab Use Only
.Lab Sample No.umber
Location Code
Location Description
Date
Collected
Time
Collected
Number of
Sample
Containers
00(,1
NJY(NA"J �0N ?A of
BluN$WrGk Co /1/aj
evlon' /S
07b/,007oQj�
0703 07011
peujr Ce
6J /8
rj, -"7 rLl
r.
0705
0070t,
CDUA
Relinqwshed by
(signature).
Date
Relinquished
Time
Reloquohed
Received by
(signature):
Date Received
Time Received
Method of Shipment (circle one): State Courier Hand -Delivered Federal Ez UPS Other:
Shipment Container Seal etl By:
(signalwo)
security Tape. Broken By:
(sgdalure)
Container/Security Tape Comments:
Vitra-LalioratorX Chain of Custody -Lab Use Only
LabSampleNumb'ers. Numberof r Analyses Relinquished Received
Sta(ting with:, , . Ending with - .:Bottles, : - Requested By By: ' Date ` Time
Y
Revised 4/12/2016