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SEQUOIA ANALYTIC SAMPLE RECEIPT LOG <br /> d <br /> T For Regulatory Puiposes? <br /> BATE RECD AT LAB: q1«(t3�1 <br /> AT LAB,CLIENT NAME: '� SA(r`t TIME REC`i� �� DRINK1hlG WATER YES 1t�D <br /> REC By(PRINT) WASTE~WATERYL-. !NO <br /> Nl�y . DATE LOQGEQ IN. - <br /> WoRKo»QER: J (For clients requiring preservation chocks at receipt,document here# ) <br /> 9 _ CONTAINER PRESERV SAMPLE~ RATE REMARK5 � <br /> CiRCI_r THE APPROPRIATE RESPONSE LAB BASK CLIENT II) CONDITION(ETC.} � <br /> SAMPLE DE,SCRIPTIOT� ATIVE pH fufATRIX SAMPLED <br /> ' vJ q!I�l 04 <br /> i Custody Seat(s) Presenil <br /> ct l Broken* <br /> 2 CYiatn of-Custod re sn Absent* <br /> 3 Traffic Reports or _� yry� <br /> Packing List Present 1 bse t <br /> Alrbill/Sticker ice'3 <br /> � Atrbd! �� 54�`t°uh 2iJo� VoPt l <br /> Present 1 s>; � 'U J <br /> S <br /> ( 5 Airbill# <br /> G Sam le Labels sc /AbsentT <br /> 7 Sample IDs- is 3Y Not Listed <br /> on Cliain-of-Cu�tad <br /> g ample Condition 49&3 1 Broken*1 ----�" <br /> Leakin <br /> 9 Does informabort on chain-of-custody, <br /> traffic reports and sample labels <br /> a ree? <�jj5 N4* <br /> 10 Sample received within <br /> hold time? N0� <br /> 1i Adequate sample volume <br /> reserved? �1 Noy` <br /> 12 Proper Preservatives <br /> used es No* <br /> 13 n an emp Bla Recelvl <br /> ( wr�ch,d s} No* <br /> 14. Temp Ree at Lab, <br /> ls temp 4-r1-2°C,? <�No" <br /> --"a tar samples requiring thermal pros 3 <br /> "r-TALS f DIFF ON ICE <br /> 'lar CIRCLED, CONTACT PROJECT MA1`U►, ASID ATTACH RECORD QF R1=50L1J TION. n <br /> Page <br />