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Page 29 of 29 <br /> � . 5 WORK ORDER #: 0 ®- © [ - F ® 0 <br /> t7v0rV, .e MI Cooler k of <br /> k <br /> SAMPLE RECEIPT FORM <br /> CLIENT: qpc (>-LS DATE: kO-2r\-W <br /> TEMPERATURE: (Criteria: 0.0°C -6.0°C) <br /> Temperature k . to °C + 1.8°C (CF) _ `� A °C Blank ❑ Sample <br /> Samples outside temperature criteria but received on ice/chilled on same day of sampling ❑ <br /> Received at ambient temperature, placed on ice for transport by Courier ❑ <br /> Ambient Temperature (For Air & Filter Only) ❑ Initial: <br /> CUSTODY SEALS INTACT: Z- <br /> ElSample El Cooler El No (Not Intact) Z Not Present Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-Of-Custody document(s) received with samples................. [�r ❑ ❑ <br /> Sampler's name indicated on COC........................................... C—�/ ❑ ❑ <br /> Sample container label(s) consistent with COC........................... ❑ ❑ <br /> Sample container(s) intact and good condition............................ ❑ ❑ <br /> Correct containers and volume for analyses requested................. ❑ ❑ <br /> Proper preservation noted on sample label(s)............................. ❑ ❑ Fl <br /> Volatile analysis container(s)free of headspace.......................... El El 2/ <br /> Tedlar bag(s) free of condensation.......................................... ❑ ❑ <br /> CONTAINER TYPE: � <br /> Soil: ❑4ozCGJ 2 ozCGJ 016ozCGJ ❑Sleeve ❑EnCores® ❑TerraCores® ❑ <br /> Water: ❑VOA ❑VOAh ❑VOAna2 ❑125AGB ❑125AGBh ❑125AGBpo4 ❑1 AGB ❑1 AG Bna2 <br /> ❑1AGBs ❑500AGB 1:1500AGBs ❑250CGB 1:1250CGBs ❑1PB ❑500PB ❑500PBna ❑250PB <br /> ❑250PBn ❑125PB ❑125PBznna ❑100PBsterile ❑100PBna2 ❑ ❑ <br /> Air: ❑Tedlar® ❑SummaOO ❑ <br /> Checked/Labeled by: Wy�, <br /> Container: C:Clear, A:Amber P:Poly/Plastic G:Glass J:Jar B:Bottle Reviewed by. _� <br /> Preservative: h:HCL n:HNO3 na2:Na2S203 na:NaOH po,:H3PO, s:H2SO4 znna:ZnAc2+NaOH Scanned by <br /> SOP T100_090(10/13/08) <br />