DOC041218-04122018151937

Chain of Custody (COC) Record - Water Samples
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Pag¢ of �—
Samples Submitted to. (-}eentral'Cab-fteigh ( )_Ashevi!IeRegienal4--ab--Swannanoa r PA LA13 141k ems A
Purpose/Investigation: Gr,�
Sample Collector/ j �,�, Dorf- �J7 CJ
Forms Completed by Print Name l9natur
Field Storage conditions & location
(».hen aDPa'cab!e).
Lab. Use Only
Lab Sample No.
Location Code
or Tag Number
Location Description
Date
Collected
Time
Collected
Number of
Sample
Containers
'
60717
007/G
?A e!
^
UO 91
�(tnNSWiGk Co !VW
D ,2 /8
�� y�
a
:.
0968 Ou&Y9
009W, a0 /
;)eN tr Ce
rly /t /8
9:2!? A
00886
008 7
C FPLAR
/l /d
c1: SS pr
Relinquished by.
(signature).
Dale
Relinquished
Time
Relinquished
Received by:
(signature):
Date Received
Time Received
/Z/l 8
; onPV
Method of Shipment (circle one): Stale Courier Hand -Deliver d-- Federal E UPS Other:
Shipment Container Sealed 8y:7
(sgnelwe)
Security Tape. Broken By:
"nalym)
Container / Secunly 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
Reviled. 4/12/1015

Chain of Custody (COC) Record - Water Samples Page ---F / of
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories --
Samples Submitted to:
Purpose / Investigation:
Sample Collector/
Forms Completed by:
ioaa[Ub--Swannanoa_C-M LuZ -
'§
Time
New
Location Code Date abor Tag Number Location Description Collected Collected Containers
� .
113 T,, n [/ , �( '"I /l1/11� �'(�/7G �, .•.,
01 Cis dF l uo� iY iv 1l G"
U. 'S 0070r7 0070
Relinquished by: Date Time Received by
(signature): Relinquished Relinquished I (signature): Date Received Time Received
»)� 41.1 ,I -owj
Method of Shipment (circle one): State Courier Band -Delivered Federal Express UPS other:
Shipment Container Sealed By: - a
(sgnature) -
Container / Security Tape Comments:
'.evised: 4/12/2016

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