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:rL-UUUTA ANAL.Y1IE,_Al_ L,A1;'1PL.E RECI-IPT l_OG <br /> CLIENT NAME ��` �rrc� DATE RRC 1) AT LAE3 % GS Fus Rcc}tflatory Purposes? <br /> 'REC BY(PRINT) U''\{ TIME REC'D AT I C�' t <br /> � I _ LAB a O DRINKINGWATER YES/ Q ti <br /> IWORKORDER, T L��! ( - DATE LOGGED IN WASTE WATER YES NO t <br /> {C{nCLE THE APPROPRIATE RESPONSE LAB JDASH CLIENT ID CONTAINER PRESERV pN SAMPLE DATE REMARKS <br /> SAMPLE# # DESCRIPTION AT1VE MATRIX SAMPLED CONDITION(ETC) <br /> 1. Custody Seal(s) Presentsent ul _ r t f�p <br /> lnixct/Broken* <br /> 2 Churn-of-Custod rase Absent �� I <br /> 3 ITraffio Reports or I <br /> Packing Usi Present/Absent I `Y <br /> 4 'Alrblll Alrblll St e-r' t <br /> i <br /> /Absent i L ✓ C <br /> b Alrblll If, 5 <br /> 6 Sam)lo Labels <br /> f'resen /Absent � <br /> 7 Sample tDs sted/ of LI <br /> 0 hal -of-Gusto <br /> it <br /> 8 Sample Cond€tionluta Broken'/ <br /> t Leakln * <br /> 9. Does information on chain-of-custody, <br /> traffic reports And sample labels <br /> n real Yes 1 No* ! `° <br /> 10 Samplo received within A <br /> hold irmB? Yes/No* I y <br /> 11 Adequate sample volume <br /> recelvod? Yes 1 No* <br /> 12 Proor E090 Rllvos used? Yes 1 No* <br /> 13 ,Trip Blank I Temp Blank Received? <br /> circle whIclh if YOEL Yes/No* <br /> 14 Read Tamp ,5 Z <br /> Corrected Temp <br /> r <br /> Is Corrected tomp 41 ROG? es No** <br /> (Accaptanco range for snmples requiring lhormal pre&) <br /> Excopllon(If any) METALS / DFF ON ICE u <br /> or Problem COC 3 <br /> r•• t a - u v e�-s�Y :e c „aura�-^L _" rr raw ,rr:+pr..a .,.�,a ..xr.1., -vr.,.�x i� ,egos ,.-.- =Y <br /> r *IF CIRCLED, CONTACT PROJECT MANAGER AND ATTACH RECORD O�RESOLUTION! <br /> j SRL Rovlslan 7 <br /> Replaces Rev 5(07113104) Page o!� <br /> I <br />