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TEST AMERICA SAMPLE RECEIPT LOG <br /> CLIENT NAME: DATE RECD AT LAB: 13107 _ For Regulatory Purposes? <br /> k <br /> REC. BY(PRINT) TIME RECD AT LAB: DRINKING WATER YES N <br /> WORKORDER: LE ct DATE LOGGED IN: L{ (off — WASTE WATER ES IN <br /> ) <br /> CIRCLE THE APPROPRIATE RESPONSE LAB CLIENT►D CONTAINER PRESER pFf SAMPLE DATE REMARKS: <br /> SAMPLE# DESCRIPTION VATIVE MATRIX SAMPLED CONDITION(ETC.I <br /> f 1, Custody Seat(s) Present/Ahs t <br /> Inta t/Broken" <br /> 2, Chain-or-Custody P(ewlit 1 Absent" _ <br /> - Traffic Reports or <br /> I <br /> Packing List: Present/A se —_ <br /> I .. <br /> 4. nirbill: Airbill/Sticker <br /> Present/ • s t <br /> 5. Airbill <br /> C. Sample Labels: resp t/Absent <br /> A 7. Sample IDs: &d/Not Listed <br /> t on Chain-of-Custody <br /> tI_ Sample Condition: 1 t /Broken"/ <br /> Leaking' — <br /> 9. Does Information on chain-of-custody, <br /> traffic reports and sample.labels - <br /> i <br /> _ agrVe? zeyl No" <br /> 10. Sample received within <br /> i hold time? le/No" — <br /> 11. Adequate sample volume <br /> received? e /No" <br /> 12. <br /> Proe2r preservatives used? NW/No" <br /> L; 13. Trip Blank/Temp Blank Received? — <br /> (circle which,It yes) Yes/ - <br /> 14.,Read Temp: Qor, — <br /> Corrected Temp: <br /> Is corrected temp 4 • 1-2°C7 e /No`" <br /> (Acceptance range for sampias requiring thermal pres.) <br /> "Exception(if any): METALS / DFF ON ICE <br /> or Problem COC <br /> "IF CIRCLED,CONTACT PROJECT MANAGER AND ATTACtf RECORD OF RESOLUTION. <br /> ces Rev 7(07/19/05) par,- of <br /> 09!13/06 <br />