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TEST AMERICA SAMPLE RECEIPT LOG <br /> CLIENT NAME: DATE RECD AT LAB: For Regulatory Purposes? <br /> REC. BY(PRINT) TIME REC'D,AT LAB: I q-1.1;c> <br /> DRINKING WATER <br /> WORKORDER: DATE LOGGED IN: (ti U$ WASTE WATER <br /> I <br /> OTHER ' <br /> CLIENT N, <br /> R C. (I <br /> i FE <br /> By <br /> WO I <br /> RKOR <br /> CIRCLE THE APPROPRIATE RESPONSE LAB <br /> CLIENT ID <br /> CONTAINER PRESER -11 SAMPLE DATE Temp. REMARKS. <br /> DESCRIPTION pH <br /> SAMPLE ION VATIVE MATRIX SAMPLED >611 <br /> C CONDITION <br /> 1. Custody Seal(s) Present <br /> Intact/Broken* <br /> 2. Chain-of-Custody (fmeTtAbsen-V <br /> 3. Traffic Reports or <br /> Packing List: Present/JG?nt <br /> 4. Airbill/Sticker-Present t s0t <br /> Tracking# <br /> 5. Sample Conditio nt kin */Broken* <br /> 6. Samples labeled <br /> No <br /> 7. Sample ID's listed on COC (fey/No-*--- • <br /> - <br /> 8. Does information on COC,-ald sample <br /> labels agree? dei/No <br /> 9. Sample received within <br /> hold time: No* <br /> 70.Adequate sample volume <br /> 10)CZ <br /> received /No* <br /> 11. Proper preservative's used Xal No* <br /> 12.Trip Blank/Temp Blank Received? L> <br /> circle which If yes) Yes 1<0 <br /> 13.Thermometer Used : IR-1 /IR-3 Backup -bP <br /> 14. Cooler RT*** CF*** CT*-* AV <br /> 4-L4-c V- <br /> 2 <br /> 3 <br /> 4 CP <br /> 5 <br /> 15. Is/Are corrected temp 0-6°C? Q/No* <br /> i-"Excepbon (if any):Metals/Perchlorate <br /> W/in 24hrs of sarngfin g-on ice Problem C'0C <br /> ilF CIRCLED,CONTACT PROJECT MANAGER AND ATTACH RECORD OF RESOLUTION <br /> **CHECK SAMPLE PREP LOG IF NOT INDICATED <br /> SAMPLERECEIPTLOG Read Temperature/Correction Factor/Corrected Temperature <br /> R eVislon 12(08107108) <br /> Page—1—of J— <br />