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Page 21 of 21 <br /> WORK ORDER #: E] ®-0 F)� -❑I ® 0 0 <br /> 'oviranim.eni--1 <br /> $��� �� ��; Inc- Cooler of <br /> t <br /> s � <br /> SAMPLE RECEIPT FORM <br /> CLIENT: '` C)\l- DATE: V0 -2-\—'38r <br /> TEMPERATURE: (Criteria: 0.0°C-6.0°C) <br /> Temperature _ 4 . 1 °C + 1.8°C (CF) __ . cN °C Blank ❑ Sample <br /> Samples outside temperature criteria but received on icelchilled on same day of sampling ❑ <br /> Received at ambient temperature, placed on ice for transport by Courier ❑ <br /> Ambient Temperature(For Air& Filter Only) ❑ Initial: <br /> CUSTODY SEALS INTACT: <br /> ❑ Sample ❑ Cooler ❑ No (Not Intact) 13'Not Present Initial:l <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of-Custody document(s) received with samples................. � ❑ ❑ <br /> Samplers name indicated on COC........................................... 5�1/ ❑ ❑ <br /> Sample container label(s)consistent with COC........................... CK ❑ ❑ <br /> Sample container(s) intact and good condition............................ Q� ❑ ❑ <br /> Correct containers and volume for analyses requested................. Ey" ❑ ❑ <br /> Proper preservation noted on sample label(s)............................. ❑ ❑ CY <br /> Volatile analysis container(s)free of headspace.......................... ❑ ❑ Q- <br /> Tedlar bag(s)free of condensation.......................................... ❑ ❑ 13-11 <br /> CONTAINER TYPE: <br /> Soil: ❑4ozCGJ 1]8ozCGJ 19 6ozCGJ ❑Sleeve ❑EnCOreSO ❑TerraCores® ❑ <br /> Water: ❑VOA ❑VOAh ❑VOAna2 ❑125AGB 0125AGBh ❑125AGBp04 ❑1AGB ❑1AGBna2 <br /> ❑1AGBs ❑500AGB 0500AGBs ❑250CGB ❑250CGBs 01PB 0500PB ❑500PBna ❑250PB <br /> ❑250PBn ❑125PB ❑125PBznna ❑100PBsterile ❑100PBna2 ❑ ❑ <br /> Air: ❑Tedlar® ❑Summa® ❑ <br /> Checked/Labeled by: � <br /> Container: C:Clear A:Amber P-Poly/Plastic G:Glass J:Jar B:Bottle Reviewed by: rr1 <br /> Preservative: h:HCL n:HN% n22:Nazs203 na:NaOH po,:H3POa s:HZSQ, znna:ZnAc2+NaQH Scanned by: <br /> SOP T100_090(10113108) <br />