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TEST AMERICA SAMPLE RECEIPT LOG <br /> CLIENT NAME: �"« � DATE RECD AT-LAB: c For Regulatory Purposes? <br /> REC. BY(PRINT) TIME REC'D,AT LAB: €�`- �' DRINKING WATER <br /> WORKORDER: 1�I.1OZ DATE LOGGED IN: 0$ WASTE WATER <br /> OTHER <br /> CIRCLE THE APPROPRIATE RESPONSE LAB— CLIENT ID CONTAINER PRESER SAMPLE DATE Temp. REMARKS; <br /> SAMPLE O DESCRIPTION VATIVE PH** MATRIX SAMPLED >60,C CONDITION <br /> 1. Custody Seal(s) Present/ <br /> Intact/Broken* <br /> 2. Chain-of-Custody resent bsent* <br /> 3. Traffic Reports or <br /> _ <br /> Packing List: Present/A�b Wnt <br /> 4, Airbill/Sticker-Present/ s <br /> Tracking# <br /> 5. ample Conditio .nt k€n *Broken* ,n <br /> 6. Samples labeled /No* <br /> 7. Sample ID's listed on COC '(Yey/No* <br /> 8. Does information on CO d sample <br /> labels agree? e /No* <br /> 9. Sample received within <br /> hold time: Y /No* <br /> 10.Adequate sample volume <br /> received /No* <br /> 11, Properpreservative's used /No* <br /> 12.Trip Blank/Temp Blank Received? <br /> circle which If yes) Yes XQ <br /> 13.Thermometer Used : IR-1 /IR-3/Backup <br /> 14. Cooler RT*** CF*'-* CT*"* <br /> 2 <br /> 3 <br /> 4 <br /> 5 <br /> 15. Is/Are corrected temp 0-6°C? Q1 No* <br /> **Exception (if any):Metals/Perchlorate/ <br /> W/in 24hrs of sam lin -on ice/Problem OC <br /> - - .•, � K ,, . ., ... , ... .:, ` !»v. � . A.�,..N.4'! v. : v.rf • .....�... .. .ri 9iv '.vhv:v ..:l., <br /> * JECT MANAGER AND ATTACH RECORD OF RESOLUTION <br /> '' 1F CIRCLED, CONTACT PRO**CHECK SAMPLE PREP LOG IF NOT INDICATED <br /> ' :. SAMPLERECEIPTLOG ***Read Temperature/Correction Factor/Corrected Temperature <br /> Revision 12(06/07/06) <br /> Page--l–of <br />