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SAMPLE RECEIPT FORM <br /> Service Request No L240 015�8 _ Client <br /> • Sample(s) delivered by Client CAS Emp 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 /> Sufficient labeling on container(s) ? Yes No (See Comments) <br /> Container(s) supplied by CAS? Yes ,� _ No (See Comments) <br /> Custody seal(s) intact9 NIA Vrr_ 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 3 °C Temp Blank'�Y r N (Circle One) <br /> Voa's Marked Preserved? Yes V/ No Filled Properly Yes J No (See Comments) <br /> Preserved Bottles Requiring pH check(s)? Yes Appropnate Preservation" Yes No <br /> RUSH Turn around time? Yes Notified Date & Time <br /> • Short Hold-Time Analysis (check all that apply) <br /> ASAP Res Cl D O Flash Diss S2- Ferrous Fe <br /> 24HR pH Odor Cr+6 <br /> 48HR BOD Color MBAS Nitrate <br /> Nitrite O-PO4 Sett Sol Turbidity <br /> 72HR Vapors <br /> Notified <br /> Date & Time <br /> Container(s) received and their preservative(s) <br /> A Nc L)Ale� <br /> 40 ml \104 CHCL-) <br /> Comments <br /> 18 <br /> 4 Initials, Date, TimeLj::� Z&ILL4 3 r 1sr formslcooler doc Rev 2/25/02 <br />