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TEST AMERICA SAMPLE RECEIPT LOG <br /> CLIENT NAME. DATE RECD AT LAB: q r <br /> For Regulatory Purposes? <br /> REC. BY(PRINT) TIME REC'D AT LAB: 11�-130 DRINKING WATER <br /> WORKORDER: NlR Tom 3q DATE LOGGED IN: Cl 191 <br /> WASTE WATER <br /> OTHER <br /> CIRCLE THE APPROPRIATE RESPONSE LAB CLIENT ID CONTAINER PRESER SAMPLE DATE Temp. REMARKS: <br /> SAMPLE A DESCRIPTION VATIVE PH rn <br /> MATRIX SAMPLED >6°C CONDITION <br /> 1. Custody Seal(s) Present/Absent <br /> Int roken* p 2 I L Avvo?- <br /> 2. Chain-of-Custody 4±re9_PRe1 Absent* <br /> 3. Traffic Reports or <br /> Packing List: Present/Absent VUP, (4) KI <br /> 4. Airbill I Sticker-Present I Absent b3 L�,- o2- — <br /> Tracking# 4+0 <br /> 0 <br /> 5. Sam cond!1 rfint <br /> t 0 _pef1Wkjng*/Broken* 032' <br /> 6, Samples labeled No—* \V Yoh F#Ci <br /> 7. Sample ID's listed on COC 4fe�L4 No* <br /> 8. Does information on COCd sample <br /> -ap <br /> 19�pi <br /> labels agree? l No' <br /> 9. Sample received within <br /> hold time: Qel No' <br /> 10.Adequate sample volume <br /> received 6zNo* <br /> 11. Proper preservatives used "e No* <br /> 12.Trip Blank/Temp Blank Received? <br /> _--(circle which jfyes) '_Yes No <br /> 13.Thermometer Used : IR-1 /0-:3V—Backup <br /> 14. Cooler RT—* CFCT— <br /> Ic <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 15. Is/Are corrected temp 0-6°C? Yes/No* <br /> 'Exception (if any): Metals I Perchlorate <br /> W/in 24hrs of samplin 2-on ice Problem COC <br /> 1F CIRCLED,CONTACT PROJECT MANAGER ATTACH RECORD OF RESOLUTION <br /> **CHECK SAMPLE PREP LOG IF NOT INDICATED <br /> SAMPLER ECEIPTLOG <br /> Read Temperature/Correction Factor/Corrected Temperature <br /> Revision 12(08/07/08) <br /> Page of <br />