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Hazardous Materials Laboratory <br /> 2151 Berkeley Way <br /> Berkeley, CA 94704 <br /> (415) 540-3003 <br /> Sample Receipt <br /> Authorization No. \• mm3 N <br /> HML Sample No(s) .Q eTM --`T gW900 Collector's No (s) .IV V-L COQ 23 <br /> Custody Seals �-P Present Absent Broken <br /> If present, location on sample(s) Over \\'CAS <br /> Sample Condition <br /> Acceptable <br /> Sample container received damaged <br /> Samples received in improper container <br /> Insufficient sample volume/weight for analysis <br /> Sample Analysis Request form not received with the <br /> sample (s) <br /> Discrepancies between the Authorization Request <br /> Form(ARF) and the Sample Analysis Request (SAR) <br /> Discrepancies between SAR information and the <br /> samples <br /> Sample Analysis Request not complete <br /> Sample containers not numbered or illegibly labeled <br /> Chain-of-custody not complete <br /> Samples received without proper preservation <br /> No information of sample preservation <br /> Other (specify) <br /> Action taken <br /> None <br /> Sample analyses on hold for further information <br /> Inform sample collector of problem <br /> Samples analyzed as received <br /> Other(specify) <br /> Name (Print) Initial Date State if Corrected <br /> �� C1f10. rtv rUlOY� 0� Zl •en. <br /> Supervisor' s approval <br />