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t7 SAMPLE RECEIPT FORM <br /> CONTROL NO. 95 03 DATE 17- 1 O -95 <br /> Z CLIENT CT C TIME I O :<w <br /> n PROJECT M O IRECIPIENT • /I�Tc--L­ <br /> SAMPLE TRANSPORTATION TO CKY LABORATORY: BY ON(DATE) AT(TIME) FROM(SITE/CO.) COMMENTS <br /> PICKED-UP BY CKY COURIER <br /> DELIVERED BY CLIENT <br /> SHIPPED/AIRBILL NOI FCDM M : 6 S d 23 11 sc—r7-/RIB I LL- <br /> SAMPLE BATCH PACKAGING/SEALING UPON RECEIPT: NO CONTAINER _ INTACTL DAMAGED NOT SEALED SEALED <br /> tr" CONTAINER: INSIDE TEMPERATURE: 2- <br /> C CUSTODY SEAL/OTHER SEAL LOCATION NUMBER <br /> Gy7 COOLER PACKAGING TYPE SUFFICIENCY INTACT DAMAGED • <br /> O BOX INSULATION: B1k- NAME: <br /> y _OTHER: ICE/COOLANT: 8 L VSE DATE: <br /> 0O PACKING MATERIAL: eRu_v '�'" TIME: <br /> RI <br /> pa <br /> SAMPLE DOCUMENTATION/CHAIN-OF-CUSTODY(COC) NONE HANDCARRIED ENCLOSED FAXED SEALED <br /> SAMPLE LOG-IN: CRITERIA COMMENTS DISCREPANCY <br /> c SAMPLE CUSTODY SEAL EVERY SAMPLE Q — <br /> CONTAINER TYPE/MATERIAL APPROPRIATE <br /> d <br /> m <br /> SAMPLE AMOUNT ENOUGH <br /> a SAMPLE PRESERVATION/HOLDING TIME SUFFICIENT <br /> HEADSPACE/BUBBLES ZERO/NONE <br /> o SAMPLE LABEL INFORMATION SUFFICIENT <br /> d CHAIN-OF-CUSTODY INFORMATION SUFFICIENT - - <br /> 0 <br /> A SAMPLE INFO.: I SAMPLE ID �j DATE TIME SIGNATURE ANALYSES PRESFRVATIVE7 CONTAINER <br /> INDIVIDUAL SAMPLE CONTAINER: NONE PLASTIC BAG CAN OTHER SPECIE : SEALED <br /> o SAMPLE NUMBER CLIENT ID DISCREPANCY ACTION • <br /> W <br /> N <br /> W <br /> H <br /> O_ <br /> T <br /> (l0 <br /> W <br /> P <br /> A <br /> O <br /> n <br /> il <br /> C <br /> J <br /> CLIENT SERVICES COPY RECEIVED BY DATE TIME <br /> L <br /> J <br /> n <br /> b <br />