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SAMPLE RECEIPT FORM Rev,No. 10 01121/04 Page Of _ <br /> -� Project Code- TB Ratch # <br /> INFORMATION IPPING CONTAINER <br /> ; ❑ Hand Delivery ❑ Ice Chest None 11 <br /> • Other❑ (Speedy) Box ❑ •• Other ❑ (Specify) <br /> Blue Ice ❑ None❑ Other ❑ Comments: <br /> hest ❑ Containers ❑ None ❑ Comments: <br /> I? Yes Ef No❑ A9 samples containers intact? Yys� �� N0 0 Description(s)matfh COC? Yes No ❑ <br /> Ice Chest ID y-e G d Emissivity �( Date/Tine <br /> /,PC S Received❑ NO T°t"�ature c container lIC BG <br /> ,YE Th ID: Analyst hiR <br /> AMPLE CONTAINERS 1 2a 5 6 7 a 9 10 <br /> IL MINERAU GENERAL PHYSICAL <br /> PRESERVED <br /> .RGANIC CHEMICAL METALS <br /> ORGANIC CHFMICAL METALS <br /> NAMDE <br /> V[TROGPN FORMS <br /> rOTAL SMFIDE <br /> NITRATE I NITRITE <br /> d TOTAL ORGAMC CARBON <br /> TOX <br /> CHEMICAL OXYGEN DEMAND <br /> PHENOLICS <br /> VIAL TRAVEL BLANK <br /> A VIAL <br /> EPA 43.1 4l 41&1 <br /> ODOR <br /> DIOLOGICAL <br /> LTERIOLOGICAL <br /> d VOA VIAL-504 <br /> EPA 509160 RMW <br /> EPA 515.IM150 <br /> EPA'575 <br /> EPA 575 TRAVEL BLANK <br /> W EPA 547 <br /> -d EPA53LI <br /> EPA 548 <br /> EPA 549 <br /> EPA 632 <br /> EPA WUM <br /> 'AMBER <br /> IZ JAR <br /> OZ-JAR <br /> .IL SLEEVE <br /> 'B VIAL <br /> .ASrIC BAG <br /> IRON <br /> 'co <br /> nments: <br /> ,pie Numbering Completed By: Date/rime: <br /> In-\00(S1WP80\lA8 pOCS\rOaMStSAMREG2 WeDI <br />