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TEST AMERICA SAMPI-RAECEIPT LOG <br /> CLIENT 61VIE: tcleir. 1kgr DATE RECD AT LAB: "_ Y Q(Z�i For Regulatory Purposes? <br /> REC.BY(PMNT) C>j TIME RECD AT LAB: DRINKING;WATER YES f NO <br /> WORKORDER.- DATE LOGGED IN: jt ���D'7 WASTE WATER YES i NO <br /> CIRCLE THE APPROPRIATE RESPONSE LAB CENT ID CONTAINER PRESEit pH SAIflIPLE DATE REMARKS: <br /> :SAMPLE# DESCRIPTION VATIVE MATRIX SAMPLED CONDITION(ETC.) <br /> 1. Custody Seal(s) Present f A4e <br /> 1• t 1 Broken" <br /> 2. Chain-of Custod a nt 1 Absent* <br /> 3. Trafflc Reports or <br /> Peskin List: Present 1 en <br /> 4.Aifbill: Airbill 1 Stick <br /> Present/A . <br /> S. Alrbill# <br /> B. Sample Labels: !Absent <br /> 7.'Sample IDs: s !Not Listed <br /> on Chaim-of Custod <br /> 8, Sample Condition: nta I Broken'! <br /> salsln <br /> 9. Does.Information on chain-of-custody, � <br /> traffic reports and iiample labels <br /> agree? <br /> 10. Sample received Wthin <br /> hold time? e I No• <br /> 11. Adequate sample volume <br /> received? e 1 No' <br /> 12. Proper reservalives used? e <br /> 13.Trip Blank/Temp Blank Received? <br /> �rr�e Whl�n.tr Yes No" <br /> 14. Reid Tamp: <br /> Corrected Temp: SIJ <br /> Is corrected temp 4+1-2'C? No" <br /> (Acceptance range far amrrpfes rerruidng thamml pm-) <br /> ception (if any): METALS 1 DIFF ON ICE <br /> or Problem COC <br /> "IF CIRCLED, CONTACT PROJECT MANAGER AND ATTACH RECORD OF RESOLUTION. <br /> %RL Rmhfon 0 4 <br />