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BC LABORATORIES INC. SAMPLE RECEIPT FORM Rev.No.12 06124108 Pae Of <br /> Submission#: il�tTjM(DOH5- - 1 <br /> SHIPPING INFORMATION SHIPPING CONTAINER <br /> Federal Express N UPS 0 Hand Delivery 0 fee Che� None 0 <br /> BC Lab Field Serrce- 0 Other 0(Specify) Box 10 Other 0(Specify)_ <br /> Refrigerant: Ice"* Blue Ice 0 None 0 Other 0 Comments: <br /> Custody Seals Ice Chest Containers 0 None f-1 Comments' : <br /> I lntapA?Yes No 0 Intact?Yes 0 No 0 <br /> All samples received? Yes 4 No o All samples containers intact? Ye Noo Description(s)match COC? Yes A./.No 0 <br /> '2 <br /> COC Received Emissivi Container:\ 4ZSThermometer 16-TW IP--� Date/Time <br /> ty -11 — <br /> ES 0 NO elzo LL:(L <br /> Temperature:A Z-) Ic I C Ic Analyst Init—UA <br /> SAMPLE CONTAINERS SAMeLE NLIMagIRS <br /> 1 2 3 4 5 6 7 <br /> OT GENERAL MINERAU GENERAL PHYSICAL <br /> PT PE UNPRESERVED <br /> OT INORGANIC CHEMICAL METALS <br /> PT INORGANIC CHEMICAL METALS <br /> PT CYANIDE <br /> ff NITROGEN FORMS <br /> PT TOTAL SULFIDE <br /> 2or-NIT TE I NI'FRITE <br /> PT TOTAL ORGANIC CARBON <br /> LRTTOX <br /> PT CHEMICAL OXYGEN DEMAND <br /> PtA PHENOLICS <br /> .Eml VOA VIAL TRAVEL BLANK <br /> 40w1 VOA VIAL 6(3)f� t ip\ 1- A 1.�N RIr t ('30 <br /> OT EPA 413.1,413.1,U8.1 <br /> RADIOLOGICAL <br /> BACTERIOLOGICAL <br /> 40 ml VOA VIAL-504 <br /> OT EPA 508/608/908() <br /> -QT EPA 515.V8159 <br /> !2T EPA 525 <br /> OT EPA 525 TRAVEL BLANK <br /> 100int EPA 547 <br /> 100mi EPA 531.1 <br /> OT EPA 548 <br /> TEPA 549 <br /> QT EPA 632 <br /> -QT EPA 8015M <br /> QT AMBER <br /> 8 OZ JAR <br /> 32 0&JAR <br /> SOIL SLEEVE <br /> PCB VIAL <br /> PLASTIC BAG <br /> FERROUSIRON <br /> ENCORE <br /> Comments: <br /> Sample Numbering Completed By: M-M-5 Date/Time: <br /> A=Actual I C=Corrected IH:IDOCMWP00ILA6_DOCS%FORMS1SAMREC2 WPD) <br />