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TEST AMERICA SAMPLE RECEIPT LOG ' <br /> CLIENT NAME: DATE REC'D AT LAB: p For Regulatory Purposes? <br /> REC. BY(PRINT) TIME RECD AT LAB: DRINKING WATER <br /> IIUORKOR©ER: '�-- DATE LOGGED IN: /BASTE MATER <br /> v OTHER <br /> CIRCLE THE APPROPRIATE RESPONSE LAB CLIENT ID CONTAINER PRESER H** SAMPLE DATE: Temp RREMARKS:SAMPLE# p <br /> DESCRIPTION NATIVE MATRIX SAMPLED >6°C CONDITION <br /> 1. Custody Seal(s) Present 1 Ab e <br /> Intact I Broker* <br /> 2. Chain-of-Custody res t I Absent* " <br /> 3. Traffic Reports or <br /> Packing List: Prese I Abs nt <br /> 4. Airbill/Sticker- present I Abs of <br /> Tracking# <br /> f 5. Sample Conditia . nta eakin *!Broken* <br /> ;. 6. Sam 1p labeled l No* ' <br /> 5 7. Sample ID's listed on COC e /No" / <br /> s 8. Does information on COC and sample f w <br /> s labels agree? l No* 14 <br /> 9. Sample received within <br /> hold time: 44e f No* f' e, <br /> 10.Adequate sample.volume a <br /> received /No* <br /> 11. Pro er preservdiWbs used l No* <br /> 12. Trip Blank I Temp Blank Received7,— <br /> circle which if vegl Yes/INIW <br /> 13. Thermometer Used : lR-1 / I - I Backu <br /> 14. Cooler RT*** CF*** CT*** <br /> [ � a �..-bl� <br /> 2 <br /> 3 <br /> { 4 ,. <br /> 5 - , <br /> 15. I'SlAre corrected temp 0-6°C? es!No* <br /> *'"Exception (if any): Metals f Perchlorate/ <br /> W/in 24hrs ofsam lin -on ice 1 Problem COG <br /> *IF CIRCLED, CONTACT PROJECT MANAGER AND ATTACH RECORD Of RESOLUTION <br /> **CHECK SAMPLE PREP LOG IF NOT INDICATED <br /> srnPLi=Rf=cEtPTt° *Read TemperaturelCorrection Factor/Corrected Temperature <br /> 4 Reftan 12(08/07/08) <br /> Page of <br />