DEQ-CFW_00025085

Chain of Custody (COC) Record - Water Samples Page i of
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Samples Submitted to: (�entral Lab - Raleigh Asheville Regional Lab - Swannanoa
Purpose / Investigation:
Sample Collector
Forms Completed by: 14 L) Q k
Print Name Signature
Field Storage conditions & location
(when applicable):
Lab Use Only
Lab Sample No.
Location Code
or Tag Number
Location Description
Date
Collected
Time
Collected
Number of
Sample
Containers
ff 17/17
13,'IY
'3
t3 doh 610j A"o tJakr­
-1 �'0_3
�t
AluEr EnlAeet 0ocEr
7/17//7
7
_81aden
M
Relinquished by:
(signature):
Date
Relinquished
Time
Relinquished
Received by:
(signature):
Date Received
Time Received
7LI7
Z7
q (P
b
7
2,),
Method of Shipment (circle one):
Eare ro�_rie
Hand -Delivered
Federal Express UPS Other:
Shipment Container Sealed By
(signature)
Securl ty Tape Broken Bd*-') S-_ 7FV
(sfgnature) IE�_
Container / Security Tape Comments:
U
7 hell 1 8 1%
Revised: 4/12/2016
DEQ-CFW-00025085