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SEQUOIA ANALYTICAL SAMPLE RECEIPT LOG <br /> CLIENT NAME' moi --- - - r DATE REC-D AT LAB 031 rAl05 For Regul?tory Purpoges? <br /> RI C.BY(PRINT) _T:q TIME REC'D AT LAB: 11011 - - - DR€NKIkU WATER YESAjPfb <br /> WORKORDER: ISL [�tl al --- DATE LOGGED IN, 3 le WASII WATER Sal NC <br /> �. (Far churns requiring preservation checks at receipt,document herel) <br /> CIRCLE THE APPROPRIATE RESPONSE LAB DASH CONTAINER PRESERV SAMPLE 'DATE REMARKS: <br /> CLfENTld, ' <br /> SAMPLE# # aESCRIPT[ON ATiVE pH isftA1'f�DC SAp►+IPt.ED CONDITION{ETC)' <br /> Y Custody Sea(S) Present se <br /> Intact!Broken* 0"1 94 P,A3 <br /> 2. Chain-of-Custadnese Absene I_t0 <br /> 3. <br /> Traffic Deports or (P <br /> wj- <br /> Packing.11st QklAbsent ✓ �4Alrbill. SWker <br /> resla Absent -g S, i, <br /> 5.Alrbill#f ��# ,31� ►�1 1 M` <br /> 6 Sample Labels: rase /Absent <br /> 7 Sample lbsList Not Listed <br /> on Chain-of-CusloqL VON <br /> a Sample Ccndatlon Sa:c-t3 B r o k Q r I <br /> Leaking* <br /> 9 Does Information on churn-of-custody, <br /> traffic reports and sample labols " - -- _ qv, -4.A twLfif�Ao 'J <br /> a <br /> agree? <br /> 10 Sample received within <br /> hold time? - es/No* --cz) € <br /> 11 Adequate sample volume <br /> roceivodl e /No* _ fi <br /> a 12 Proper Preservatives i <br /> used? <br /> —rip B1Bien calved? <br /> arvlawhich,alyes) es No* <br /> 14,Temp Rec at LAb 4�0 <br /> Is temp 4+1--2°C? rss Na*' <br /> :.vcepbon(if any) ME='T'AL FF ON ICF <br /> i„�� �IEvClt1C LEuL), �t �� I .'ILU,]L(-j frtJltj, IAtiA1 OF RESOLUIICAN. <br /> Page <br /> R I17h 3104 <br />