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�Ir �w I� � � ■w � � � � � r 11■r ■� ! r 11� a � <br /> TEST AMERICA SAMPLE RECEIPT LOG <br /> CLIENT NAME: 1p/n-<L� \\p( DATE REC'D AT LAB: 10j (IG(j o For Regulatory Purposes? <br /> REC. BY(PRINT) (� ,V . TIME RECD AT LAB: lL� DRINKING WATER YES/ NO <br /> WORKORDER: �DFj 3 DATE LOGGED IN: 0 23 t)-} WASTE WATER YES/ NO d <br /> { CIRCLE THE APPROPRIATE RESPONSE LAB CONTAINER PRESER SAMPLE DATE s <br /> pH REMARKS: <br /> R SAMPLE# CLIENT ID DESCRIPTION NATIVE MATRIX SAMPLED CONDITION (ETC.) <br /> 1. Custody Seal(s) Present! bse <br /> Iota / Broken' <br /> R <br /> 2. Chain-of-Custod P ese t/Absent" <br /> 3. Traffic Reports or <br /> Packin List: Present/ se <br /> 4. Alrbill: Alrbill /Sticker <br /> p Present/ bse t <br /> fl 5. Alrbill d/: <br /> 4 <br /> 6. Sample Labels: /Absent <br /> 7. Sample IDs: LkteP Not Listed <br /> on ain-of-Custod <br /> 8. Sample Condition: I /Broken-/ <br /> Lea in " <br /> 3. Does information on chain-of-custody, <br /> traffic reports and sample la 13 <br /> agree? / No" <br /> 10. Sample received within rMs <br /> hold time? Yes)/ No* <br /> 11. Adequate sample volume <br /> received? /No* <br /> 12. Proper preservatives used? <br /> 13. Trip Blank/Temp Blank Received? <br /> (dale which,If yes) Yes/ No <br /> 14. Read Temp: { <br /> ( Correction Factor: r3 <br /> Corrected Temp: - <br /> Is correrted temp. 0-6°C? !No"" <br /> ""Exception (if any): METALS I DFF ON ICE k <br /> or Problem COC <br /> SAMPLERECEIPTLOG "IF CIRCLED, CONTACT PROJECT MANAGER AND ATTACH RECORD OF RESOLUTION. <br /> Revision 8(09/26/07) Page of__�__ <br />