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i <br /> SEQUOIA ANALYTIC*AMPLE RECEIPT LOG <br /> I - -....* I I I . I ", ­ -1 --, - �1 -,, " "IM-F ,�-=- , - - .- - - - -.-- f . -- <br /> C:LIEN r NAME { - DATE Received at Lab Q L (Drinking 1iater) for <br /> REC BY (PRINT) C.jJ regulatory purposes YESINO <br /> � TIME Received at Lal, ��� <br /> tiVORKOItDER �C / CS t { LOG IN DATE; t1�7f�� (waster4ater)for <br /> regulatory purposes- YESINO <br /> CIRCLE THE APPROPRIATE;RESPONSE LAB Dash CONTAINER SAMPLE DATE I <br /> SAMPLE# # CLIENT ID DESCRIPTION pH MATRIX SAMPLED CONDITION (ETC ) <br /> IW F-/A-z &V'O� I"A t / i <br /> i Custody Sealts) Present/ bse <br /> Intact 1 Broken* <br /> 2 Chain-of-Custody r t/Absent* <br /> `i Airbill I`� iribill 1)Sticker <br />� rase t'/Absent <br /> 4 11iibifl# ,E�� <br /> 5 Sample Labels res t/Absent <br /> 6 Sample i Ds tst 1 Not Listed <br /> ain-of-Custod <br /> 7 Sample CondaionntcR t/Broken*/ <br /> Leaking" <br /> 8 Docs tnfatniaiion on custody reports, <br /> traffic teputts, and sample <br /> labels a rt,0 e /No* <br /> 9 Sample ieceived within <br /> hold time /me1 No's <br /> 10 Piuper Preseivatives f, / <br /> used (It—p/Ng 7L1() <br /> 11 Tcm 3erature Blank Ref elved? Yes/ ` <br /> 12 Temp Rec at Lab G z aLgf=S e <br /> (A(xeptanc,e Lange for samples v <br /> req utrtnt thermal fes 4+1-2°C) Y /No's <br /> 13 Samples collected mole <br /> dials 4 da s a 0 Yes 1 <br /> 5 ♦ E ti< V L1SCf YLYI A d ..V;T iT 9 1"3 L2 R !rY '#.>'!L 4wKx t i m Mv^ i t'S<7— 77 .,.f L ' ^ C Gt is\!a✓ f e F ^x i "'_ — <br /> *If Circled, contact Project Manager and attach record of resolution. <br /> Sample Rece;pl Log <br /> Rewslon 2 2(8130104) Page of <br /> Replaces aevislon 2 1 (1 Ill 0100) <br /> FIGURE fib <br />