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_ h <br /> s <br /> SAMPLE RECEIPT FORM <br /> f <br /> Service Request No: L23 Q� 16.1_ Client: M W k!!c <br /> Sample(s) delivered by: Client CAS Emp After Hours DHL i <br /> Golden State Overnight Fed X UPS Other Courier <br /> Chain of Custody filled out accurately? Yes No (See Comments) <br /> Appropriate sample volume and containers? Yes >` No (See Comments) <br /> i <br /> Sufficient labeling on container(s) 7 Yes X No (See Comments) <br /> Container(s) supplied by CAST Yes No X (See Comments) <br /> Custody seal(s) intact? NIA Yes No (See Comments) <br /> Trip Blank(s) received Yes No �Cr' <br /> i <br /> ff Trip Blank was supplied by CAS, record serial # =TB- <br /> Temperature of sample(s)/cooler °C Temp Blank? Y o0circie One) <br /> Voa's Marked Preserved? Yes No Filled Properly? Yes No (See Comments) <br /> Preserved Bottles Requiring pH check(s)? Yes Appropriate Preservation? Yes No ' <br /> RUSH Turn around time? Yes Notified Date& Time <br /> Short Hold-Time Analysis (check all that apply) <br /> ASAP ices Cl D.O Flash Diss S2- Ferrous Fe <br /> 24HR pH Odor Cr+6 <br /> 48HR BOD Color MBAS Nitrate <br /> Nitrite O-PO4 Sett Sol Turbidity <br /> 72HR Vapors <br /> I <br /> i <br /> Notified Date& Time j <br /> Container(s) received and their preservative(s): <br /> v �� w-�� L- <br /> i ti <br /> 3 1 L ArC,- <br /> 7 <br /> a <br /> Comments <br /> r <br /> s <br /> I <br /> I <br /> I I <br /> Initials, Date, Time 1J l �CQ X �7., r:lsr formslcooler,doc Rev. 2/25/02 <br />