DEQ-CFW_00069978

Chain of Custody (COC) Record - Water Samples Page of 1
North Carolina Division of Water Resources - Water Sciences Section Chemistry Laboratories
Samples Submitted to: (t,,) Central Lab - Raleigh ( ) Asheville Regional Lab - Swannanoa
Purpose / Investigation: ,
Sample Collector/
Forms Completed by: Prinf 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
1355
s-10-17
1155
NJ✓r P- -/h;shed
JW) 17
2
Z/r)L/ M
0.
I
C
Relinquished by:
(signature):
Date
Relinquished
Time
Relinquished
Received by:
(signature):
Date Received
Time Received
Z
��7
qm
0930
Method of Shipment (circle one) : ate Courier Hand -Delivered Federal Express UPS Other:
Shipment Container Sealed By:(�,
(signature) f� Kj��i91
Security Tape Broken
(signature)
Revised: 4/12/2016
DEQ-CFW 00069978