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TEST AMERICA SAMPLE RECEIPT LOG <br /> FChain-of-custod!Z <br /> AME: DATE RECD AT LAB: /�,Q <br /> ����Sb.—�=� �' For Regulatory Purposes? <br /> (PRINT) ;k� TIME RECD AT LAB: D D <br /> Z RINKING WATER YES f <br /> DER: Q,SqDATE LOGGED IN: O WASTE WATER 'E I NO <br /> HE APPROPRIATE RESPONSE LAB CLiEN7 fD CONTAINER PRESER PH SAMPLE DATE REiY1ARKS: <br /> SAMPLE# DESCRIPTION VATIVE MATRIX SAMPLED CONDITION(ETC.) <br /> eal(s) Present/A s tIntact/Broken* <br /> PlEs.,jLit/Absent" <br /> 3. Traffic Reports or <br /> Packing List: Present/A se t <br /> 4. Airbiil: Airbiil/Sticker g <br /> Present/AG-It t <br /> 5. Airbiil#: <br /> a. Sample Labels: P esa t J Absent <br /> 7: Sample IDs: L'st d J Not Listed <br /> on Chain-of-Custody <br /> 8. Sample Condition: IEt/ Broken* AI <br /> ! <br /> Leaking* (/ <br /> r 9. Does Information on cliain-of-custody, <br /> ; <br /> tra#flc reports and sample labels <br /> a roe? 191 No* <br /> 10. Sample received within — r <br /> hold time? e /No* <br /> 11. Adequate sample volume <br /> received? e !No* <br /> 12. Proper preservatives used? e /No* <br /> 13.Trip Blank/Temp Blank Received? <br /> ) t <br /> (circle which,if yes) Yes/0 zg <br /> 14..Read Temp: (p <br /> y Corrected Temp: i <br /> . a <br /> Is corrected temp 4.F/-2°C? e !No** <br /> (Acceptance range for samples requiring thermal pros.) <br /> *"Exception(if any): METALS / DFF ON ICE <br /> or Problem COC <br /> *IF CIRCLED,CONTACT PROJECT MANAGER AND ATTACH RECORD OF RESOLUTION. <br /> SRL Revision 8 <br /> Rev 7(07118105) <br /> 'U9113108 <br />