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1 <br /> TEST AMERICA SAMPLE RECEIPT LOG <br /> CL.IEIIIT NAME: A t/1S 13ATE RECD AT LAB: 1 7--7- bg Fvr Regulatory Purposes? <br /> REG.BY(PRINT) m TIME REVD AT LAB_ p� _ DRINKING WATER <br /> WORK+7RDER: �f {A���y !]ATE LOGGED IN: JT, ?r yrs — IYASTE WATER <br /> f OTHER <br /> CIRCLE THE APPROPRIATE RESPONSE LAB CONTAINER PRESER SAMPLE DATE REMARKS: <br /> SAMPLIE# CLIENT IU DESCRIPTION VATIVE pH MATRIX SAMPLED CONDITION(ETC.) <br /> 1. Custody Seal(s) P I Absent <br /> Intact f Bmken` <br /> 2. Chain-of-Custvd Pr 1 Abserir f <br /> 3- Traffic Reports or <br /> Packing List: Present 1 t <br /> 4_ Airbill_ Ajrbill I Stickel <br /> P21Etnt/Aunt <br /> S_ Alrbill#: SSE _ <br /> B. Sample Labels: P&Lmt I Absent f �1 <br /> 7. Sample]Ds: Li I Not Listed <br /> on Chain-of-Custody <br /> S. Sample Condition: Ideo I Broken"f <br /> Leakln " <br /> 9, Does information on chain-of-custody, <br /> traffic reparts and sample labels <br /> a reed f Ne <br /> 10. Sample received uviWn <br /> hold time? 6—e i No* <br /> 1-1. Adequate sample voltane <br /> reoeived7 1 No* <br /> 12. Pro r ereservativs used? I Na* <br /> 13.Trip 1 k I Te lank Received? <br /> (G-M*+8 Oh,eyes) e3 f No* <br /> 14.-Read Temp: 7&IF C. <br /> Correction Factor: I•a'C <br /> Ccarraected Temp: <br /> Is corrected temp. G-TC? !No"* <br /> t.Exception it an Metals I Perchlorate <br /> DFF on Ice or Problem COG <br /> *IF CIRCLED,CONTACT PROJEGT MANAGER A140 ATTACH RECORD OF RESOLUTION_ <br /> SAMPLEREGBPnOG J <br /> Page k of <br /> Reul�pce 9(10r2fj�QT� <br />