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<br />SAMPLING RECORD <br /> <br />Person Sampling: <br /> <br />Date: <br /> <br />T irne : <br /> <br />am/pm <br /> <br />Facility Sampled: <br /> <br />Facility Location: <br /> <br />Sampling Location: <br /> <br />Samp le Type: <br /> <br />Grab [] <br /> <br />Composite [] <br /> <br />Observation/Comments: <br /> <br />Sample Bottle I.D. (Marking) <br /> <br />Samples split with facility? <br /> <br />Yes <br /> <br />[ ] <br /> <br />No [] <br /> <br />Name of Facility Representative: <br /> <br />Title of Facility Representative: <br /> <br /> SAMPLE AFFILIATION/ <br />TIME/DATE RECEIVED BY SIGNATURE TITLE COMMENTS <br /> <br /> <br /> <br /> <br /> <br />-74- <br />