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SAMPLE RECEIPT FORM <br /> Service Request No L240 aClient APPL I L <br /> Sample(s) delivered by Client CAS Ernp After Hours DHL <br /> Golden State Overnight Fed X UPS Other Courier <br /> Chain of Custody filled out accurately? Yes No {See Comments) <br /> Appropriate sample volume and containers? Yes No (See Comments) <br /> p <br /> Sufficient labeling on container(s) ? Yes No (See Comments) <br /> Container(s) supplied by CAS? Yes _ No7(See Comments) <br /> Custody seal(s) intact? NIA i/ Yes No (See Comments) <br /> Trip Blank(s) received Yes No � <br /> If Trip Blank was supplied by CAS, record serial # -TB- <br /> Temperature of sample(s)/cooler °C Temp Blank? Y o(N ircle One) <br /> Voa's Marked Preserved? Yes No Filled Proper1y9 Yes No (See Comments) <br /> Preserved Bottles Requinng pH check(s)9 Yes Appropriate Preservation`s Yes No <br /> RUSH Turn around time? Yes Notified Date &Time <br /> Short Hold-Time Analysts (check all that apply) <br /> ASAP Res Cl D O Plash Diss S2- Ferrous Fe <br /> 24HR pH Odor Cr+b <br /> 48HR BOD Color MBAS Nitrate <br /> Nitnte O-PO4 Sett Sol Turbidity <br /> 72HR Vapors <br /> Notified Date & Time <br /> Container(s) received and their preservative(s) <br /> f <br /> Comments <br />�1 <br /> / o <br /> f z30 <br /> Initials, Date, Time L r 1sr formslcooler doc Rev 2/25io2 <br />