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i mewum HIS r t L_ ,t1wr Lel M I Jl.i i i i i <br /> 'NAME; BATE rI 'DAT LAB: ' r far RegtilatoryPurposes? <br /> REC. BY(PRINT) 7JME RECID AT LAB: <br /> . � ___-- DRINKING WATER <br /> WOr?KORDER: 1`'l if t, DATE LOGGED IN; WASTE WATER YES I j1f <br /> } (Far clionts requiring preservation chucks at receipt,dacament burro <br /> CIRCLE THE APPROPRIATE RESPONSE LAB DASII CONTAINER PRESERV SAMPLE DATE REMARKS-. <br /> SAMPLE# ff CLIENT Irl DESCRIPTION A'11VI= PR MATRIX SAMPLED CONDITION(ETC.) <br /> i. Cus#cx3y Saal(s) Presont I <br /> i Broken �r � <br /> 2. Chain-of-Guslod 1're I Absont' <br /> 3. Traffic Reports or •" jl , <br /> Packing List- Fresept se <br /> 4. Alrblfk Alrb tic <br /> res bsent <br /> 5. AirtnlJ l€; ` <br /> 6. Sample Labols: /Absent [ <br /> 7. Sampla IDs: ,Is !Not LFsted_ fi <br /> ffla <br /> cin-of-Guslocl <br /> 8. Sarn&Condition: !Broken*I <br /> Leaklry ` 40 <br /> 9. Does information un chain-of-custody, ��r2x)?A <br /> traffic reports and samplela bals <br /> agree? t No* <br /> 10. Sanlp!o received withln <br /> hold tim e? !No* <br /> 11. Adequata sample volume <br /> re ceh,ed? <br /> 12. Proper Preservatives p� <br /> Ne <br /> 3.Trip BI omp Blank R ived? <br /> circle which,it yrs) Ys No* <br /> }" i4.Temp Rea al Lab c- <br /> ': ;f:- Is temp 4+1-2'C? <br /> r, AUl alance m <br /> .( p rx�e torsarnplas raquirirxl rhgrmRE pries.} <br /> "Exc©ptiort(if any): METALS I BF=F ON ICJ= <br /> t< xOT Problem COC <br /> �'* 4:f+9ti> Y viliVG 7l8t1:' _tirjY/VSSJSii <br /> t :, 'IF CIRCLED,CONTACT PROJECT MANAGER AND ATTACH RECORD OF F1ESOLUTIOM. �A <br />