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(7 SAMPLE RECEIPT FORM <br /> CONTROL NO, 95 03 DATE 1 1- }0 -95 <br /> CLIENT CT C! TIME Io <br /> �j PROJECT / A[ 0 RECIPIENT <br /> b SAMPLE TRANSPORTATION TO CKY LABORATORY: BY ON(DATE) AT(TIME) FROM(SITE/CO.) COMMENTS <br /> PICKED-UP BY CKY COURIER <br /> DELIVERED BY CLIENT <br /> SHIPPED/AIRBIILL.N01 F-b -frJ . 6 S Q 2-.i} S6:AlizA I LL-- <br /> SAMPLE BATCH PACKAGING/SEALING UPON RECEIPT: NO CONTAINER INTACT DAMAGED NOT SEALED SEALED <br /> ( ' CONTAINER: INSIDE TEMPERATURE: Z C CUSTODY SEAL/OTHER SEAL LOCATION NUMBER <br /> COOLER PACKAGING TYPE SUFFICIENCY INTACT DAMAGED i <br /> O BOX INSULATION: NAME: <br /> °y _OTHER: ICE/COOLANT: 8 E- bU6 DATE: <br /> PACKING MATERIAL: f� TIME: <br /> pa <br /> rn <br /> SAMPLE DOCUMENTATION/CHAIN-OF--CUSTODY COC) NONE HANDCARRIED ENCLOSED FAXED SEALEDLLJ <br /> SAMPLE LOG-IN: CRITERIA COMMENTS DISCREPANCY <br /> o SAMPLE CUSTODY SEAL EVERY SAMPLE <br /> 9 CONTAINER TYPE/MATERIAL APPROPRIATE <br /> a. <br /> a SAMPLE AMOUNT ENOUGH <br /> a SAMPLE PRESERVATION/HOLDING TIME SUFFICIENT <br /> C <br /> HEADSPACE/BUBBLES ZERO/NONE <br /> o SAMPLE LABEL INFORMATION SUFFICIENT <br /> CHAIN•-OF-CUSTODY INFORMATION SUFFICIENT <br /> P SAMPLE INFO.: SAMPLE ID 1 DATE TIME SIGNATURE ANALYSES PRESERVATIVE CONTAINER <br /> INDIVIDUAL SAMPLE CONTAINER: NONE PLASTIC BAG CAN OTHER SPECIFY : SEALED <br /> r, SAMPLE NUMBER CLIENT ID DISCREPANCY ACTfON <br /> t S. i t r-L — r S 9 r i l S� onj 7-i.G-Z,*—,fit , <br /> W <br /> w <br /> Ca <br /> 00 <br /> m <br /> aoa <br /> v <br /> CLIENT SERVICES COPY RECEIVED BY DATE TIME <br /> b <br /> 1 <br /> 20 <br />