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SAMPLE RECEIPT FORM 1 <br /> t_S>Il C_ <br /> Type ofDelivery Delivered B /Airbill ECN L g+ <br /> ❑EMAX Courier 3—,o <br /> Rece fentt �/ <br /> ❑Client Delivery Date 1 2 ( C '-C �a <br /> rrd Party Time r'L <br /> COC Inspection <br /> -t Client Name 9 client PM/FC —Q4ampler Name —CSampling Date/fime/Location 151hiniple ID ,.QUatrix <br /> dress CPMT i/Fax# ❑Courier Signature 07M lysis Required LTlsreservative(if any) STAT <br /> Safety Issues <br /> None ❑High concentrations expected ❑Superfund Site samples ❑Rad screening required <br /> Comments: <br /> Packaging Inspection <br /> Container ❑❑C ❑Box ❑Other <br /> Condition ❑Custody Seal ntact ❑Damaged <br /> Packaging Pack > ❑Styrofoam ❑Popcorn A@-Bafficient <br /> Temperatures `'Q-Looler A. "C ❑Cooler 2 "C ❑Cooler 3 "C ❑Cooler 4 "C ❑Cooler 5 "C <br /> ❑Cooler 6 "C D Cooler 7 "C ❑Cooler 8 °C ❑Cooler 9 "C ❑Cooler 10 "C <br /> Comments: ❑PM was informed on non-compliant coolers imediately. <br /> DISCREPANCIES <br /> LSID LSCID Sample Label ID/COC ID Discrepancy Code Corrective Action Code <br /> & (2- 1SZl > o �,tnwk- <br /> 12.1 1 e( e "t- (,i s <br /> t <br /> t <br /> REVIEWS JS <br /> �`.�lV 9 <br /> Sample Labe in, { SRF PM <br /> Date y l '-tt Date 1p Q� Date <br /> I PPE <br /> LEGEND: <br /> Code Description-Sample Management Code Description-Sample Management Code Description-Project Management <br /> A I Analysis is not indicated in COC El Preservative needed;sample has no preservative RI Hold sample(s);wait for further instructions <br /> A2 Analysis is not indicated in label E2 Preservative not needed but sample is preserved R2 Proceed as indicated in COC <br /> A3 Analysis is inconsistent in COC vis-ii-vis label Fl Not enough quantity ofsamples R3 Refer to attached instruction <br /> B 1 Sample 1D is not indicated in COC F2 Bubble is>6mm R4 Cancel the analysis <br /> B2 Sample ID is not indicated in label G I Temperature is out of range(4+ 2"C) R5 <br /> i <br /> B3 Sample ID is inconsistent in COC vis-i-vis label G2 Out of Holding Time R6 <br /> CI Wrong container G3 >20%solid particle <br /> C2 Broken container H I <br /> C3 Leaking container H2 <br /> DI Date and/or timc is not indicatcd in COC <br /> D2 Date and/or time is not indicated in label <br /> D3 Date and/or time is inconsistent in COC vis-A-vis label <br />