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TEST AMERICA SAMPLE RECEIPT LOG <br /> CLIENT NAME: DATE REC"D AT LAS: ' <br /> _ �� za '( For Regulatory Purposes? M <br /> REG. BY(PRINT) TIME RECD AT LAB: — - 2z�1 p DRINKING'WATER Yr--'s I NO <br /> INORKORDER: � "214 0019 DATE LOGGED IN: WASTE WATER YES I NO <br /> CIRCLE THE APPROPRIATE RESPONSE LAB CONTAINER PRESER SAMPLE DATE <br /> CLIENT ID R REMARKS: <br /> SAMPLE# DESCRIPTION VAT1VE P MATRIX SAMPLED CONDITION(ETC.) <br /> x •t. Custody Seals) Present i A sen 0 1r1 w L 1.� 8 Zt�c17 <br /> Intact I Broken` rt L 1 / <br /> 2. Chain-of-Custodyf resent/Absent* <br /> 3 Traffic Reports or r <br /> S Packing List. Present 1 bs t <br /> 4, Airbill: Airbil!f Sticker <br /> ,r <br /> i, Present <br /> 5. Airbill#-. <br /> k6- Sample Labels: res I Absent _ <br /> 7. Sample ll)s:� List I Not Listed <br /> on Chain-of-Custody <br /> 8- Sample Condit€on: t�Broken`I <br /> Leakirr " <br /> 21 <br /> } 9. Does Information on chain-of-custody, <br /> traffic reports and sample labels <br /> at)reQ? Ye No* �. <br /> lit. Sample received vfithin <br /> hold tlms? ge-s-f No fi <br /> 11. Adequate sample volume <br /> d <br /> received? I Nd* <br /> 12. Proper reserv2t€ves used? e 1 No' :-� 4 <br /> k 13. Trip Blank I Temp Blank Rece€v ? <br /> a (circle which,jr yes) Yes I Ido <br /> 14-Read Temp: . <br /> Corrected Temp: <br /> n <br /> Is corrected temp 4+-1-•2°C? Y /No"* 9 <br /> (Accep(ance range far samples requiring thermal pres_) <br /> "`Exception (if any): METALS / DFF ON ICE N <br /> or Problem COC a <br /> .• <br /> *IF CIRCLED, CONTACT PROJECT MANAGER AND ATTACH RECORD OF RESOLUTION. <br /> SRL Revision e l <br /> Replaces Rev 7(07113105) Page_of� <br />