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EM1RTkMT"* AMErOM, IM <br /> Custody Transfer Record/Lab Work Request - J <br /> Refri orator# LAB USE ONLY <br /> S L> <br /> it/Type Container Samples Were <br /> Client Volume 1 Shipped or Hand <br /> Work Order d Delivered <br /> Preservative <br /> Preservative NOTES <br /> Date Rec d Date Due �� <br /> ANALYSES 2 Ambient or Chilled <br /> Client ContacUPhone � �4�� REQUESTED �Q NOTES <br /> Client ID/Description Matrix Date <br /> Lab ID Collected , 3 Received Broken/ <br /> irj � > to� -43 ✓ ��' ct� ` . .C� Leaking (Smproperly <br /> Sealed) <br /> Z - Sr I Y N <br /> NOTES <br /> S 4 Properly Preserved <br /> 2 Y N <br /> NOTES <br /> — 310 5 Received Within <br /> 3 5 Holding Times <br /> Y N <br /> NOTES <br /> LI - s <br /> -S� COC Tape Was <br /> _ 5 1 Present on Outer <br /> } Package Y N <br /> 2 Unbroken on Outer <br /> 6 Package Y N <br /> 3 Present on Sample N <br /> Matrix W Water DS Drum Solids X Other Special instructions 4 Unbroken on Sample <br /> S soil 0-011 DL Drum Liquids 5? I � ;�] NOTES Y N <br /> SE-Sediment A-Air F-Fish <br /> SO-Solid Wt Wipe L- EPfrCLP Leachate L rk (J t^�� t cc. (C-q-01) r7 <br /> CDC Record Was <br /> Item/Reason Relinquished b Received to Date Time Item/Reason Relin urshed b Received b Date Time 1 Present Upon Receipt <br /> rC(,( - �t /-/7- of Samples Y N <br /> Dtscrepanc:es Between <br /> Sample Labels and GOC <br /> Record? Y N <br /> NOTES <br />