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SAMPLE CEIPT FORM <br /> Lo c)o o <br /> Service Request No L� Client: !U <br /> Sample(s) delivered by: Client CAS Emp After Hours DHL <br /> Golden State Overnight Fed X \,�"UPS Other Courier <br /> Chain of Custody filled out accurately? Yes V 'No (See Comments) <br /> Appropriate sample volume and containers? Yes VNo (See Comments) <br /> Sufficient labeling on container(s) ? Yes ✓� No (See Comments) <br /> ✓�-No See Comments <br /> Container(s) supplied by CAS?�. Yes ( ) <br /> Custody seal(s) intact? N/A Yes No (See Comments) <br /> Trip Blank(s)received Yes No <br /> If Trip Blank was supplied by CAS, recon serial # -TB- <br /> Temperature of sample(s)/cooler °C Temp Blank or N(Circle 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 Res Cl D.O Flash Diss S2- Ferrous Fe <br /> 24 If RpH Odor Cr+6 <br /> 48 BOD Color MEAS Nitrate <br /> Nitrite O-PO4 Sett Sol Turbidity <br /> 72HR Vapors <br /> Notified �i" �i/ Date&Time 1146 10450 <br /> Container(s) received and their preservative(s): <br /> 1 ' 3 -- 0-7x.7 KL (jDU<+-C <br /> Comments <br />