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ACCESSION INITIALS: <br /> q 1q hfgo <br /> -�'SkJIPLE;`CONDITION it! 'RECEIPTE EMIS <br /> UPON.......... .... ... <br /> CCFSSIONS"::COAI:PLETF,'#7-..hMt <br /> (FOR REk <br /> . ......... <br /> 1 Does this project require special handling according to NFESC Levels C, D, YES NO <br /> AFCZE or CLP protocols? <br /> If yes, complete a)and b) <br /> a) pH sample aliquoted: yes /no /na <br /> b) Either 1) Record Bottle Lot Vs: <br /> Or 2) Attach Sample Kit Request Forms) <br /> 2 Number of Coolers Received <br /> If more than one cooler received attach Multiple Cooler Documentation Form <br /> (MCD) <br /> Indicate "see XCO"an item 11 below <br /> 3 Are custody seals required for this project ? <br /> YES (�XIAD <br /> a) are Custody Seals present on Cooler(s) ? YES <br /> NO <br /> If yes, are seals intact ? ad YES NO <br /> b) are Custody Seals present'on the sample ? <br /> YES NO <br /> If yes, are seals intact ? NO <br /> 4 Is there a Chain-Of-Custody (COC)' per cooler NO <br /> it not, if a problem is found indicate which samples/test were in the <br /> affected cooler on the MCD. <br /> 5 Is the COC* comp per cooler ? YES <br /> ��S NO <br /> Relinquished: (,ye;:;I/no Requested analysis yes no 'C <br /> 6 Is the COC* reement with the samples received' YES NO <br /> Sample ID's: IIZ5 _Yno Date sampled: <br /> # <br /> Samples .ay �De /no <br /> Matri . es 0 # containers: <Y--e-/no <br /> •1 7 Are the samples preserved correctly? YES NO <br /> a Is there enouch sample for all the requested analyses? NO <br /> 9 Are all samples within holding times for the requested analyses? YES NO <br /> 10 Record cooler temperature. Contact PM if temperature is not 4°C ± 21C. -3.0 6C <br /> Is ice present in cooler? —7s-7 NO <br /> 11 Were all sample containers received intact (ie. not broken, leaking, NO <br /> etc.)? �aQ <br /> 12 Are samples requiring no headspace, headspace free? N/A Cap NO <br /> 13 Are VOA Ist stickers required? YES NO <br /> 14 Are there special comments on the Chain of Custody which require client YES <br /> contact? <br /> 15 If yes, was ATI Project Manager notified? YES NO <br /> Describe *no" items: <br /> Was client contacted? yes / no <br /> If yes, Date: Name of Person contacted: <br /> Describe actions taken or client instructions: <br /> Or other representative documents, letters, and/or shipping mens <br /> A71-7ZX90 2(0 3/95) <br />