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SAMPLE RECEIPT FORM <br />Service Request No: P0700 cJ Client: J H*V <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 No (See Comments) <br />Appropriate sample volume and containers? Yes No (See Comments) <br />Sufficient labeling on container(s) ? Yes No (See Comments) <br />Container(s) supplied by CAS? Yes No (See Comments) <br />Custody seal(s) intact? N/A s✓ Yes No (See Comments) <br />Trip Blank(s) received Yes J No <br />If Trip Blank was supplied by CAS, record serial # -TB- <br />Temperature of sample(s)/cooler °C Temp Blank?(DN o N (Circle One) <br />Voa's Marked Preserved? Yes x,/ No Filled Properly? Yes � No (See Comments) <br />Preserved Bottles Requiring pH check(s)? Yes \/ Appropriate Preservation? Yes V/ No <br />RUSH Turn around time? Yes Notified Date & Time <br />Short Hold -Time Analysis (check all that apply) <br />ASAP <br />24HR <br />48HR <br />RUM <br />Notified <br />Res Cl— D.O Flash_ Diss S2- <br />pH Odor Cr+6 <br />BOD Color MBAS <br />Nitrite O-PO4 Sett Sol <br />Vapors <br />� <br />U <br />Container(s) received and their preservative(s): <br />t-is-&rAv (WO <br />t 5(x) ft l nc C moo - <br />Ferrous Fe F&P <br />Nitrate V/ <br />Turbidity <br />Date & Time �- /4JU <br />Comments i <br />Initials, Date, Time V �I CO r7 W11-0 rAsr forms\coolendoc Rev. 2/25/02 <br />