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SEQUOIA ANALYTICAL SAMPLE RECEIPT LOG <br /> CLIENT NAMEWORKORDER <br /> : REC BY(PRINT) DATE OF LOG-IN Z <br /> CIRCLE THE APPROPRIATE RESPONSE LAB SAMPLE DASH CLIENT CONTAINER SAMPLE DATE REMARKS <br /> 1 Custody Seal(s) Present I Amit # # IDENTIFICATION DESCRIPTION MATRIX SAMP CONDITION(ETC ) <br /> Intact 1 Broken" <br /> 2 Custody Seal Nos Put in Remarks Section <br /> t 3 Cham-of-Custody 03 1 y <br /> Records Pint I Absent* 0 20 <br /> 4 Traffic Reports or <br /> 1 Packing List Present/Ab9W <br /> 06 " <br /> 5 Airbill Airbill/Sticker O� 1 r <br /> } 4 Present 1 Abort 0E <br /> 6 Airbill No C)C) z , �l�"�" core- <br /> 7. Sample Tags Int!Absent* <br /> fr Sample Tag Nos LfMa/Not Listed 1 ° <br /> <{ on Chain-of-Custody I2� <br /> >' 8 Sample Condition JMW/Broken*/Leaking* 13 Z° <br /> ;# 9 Does information on custody �y S <br /> {} reports, traffic reports and <br /> sample tags agree? 2M I No* <br /> 10 Proper preservatives <br /> used /No* <br /> ? 11 Date Rec. at Lab <br /> 2; 12 Temp Rec. at Lab <br /> 13 Time Rec. at Lab l�y <br /> * if Circled, contact Project manager and attach record of resolution <br /> Revision 3121195 <br /> - Page � of�L <br />