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SAMPLE RECEIPT FORM <br />Service Request No: P0700 I L5 Client: 3 H -AW <br />delivered b : Client CAS Em After Hours DHL <br />Sample(s) Y p <br />Golden State Overnight Fed X UPS _V_ 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 />Containers supplied b CAS? Yes No See Comments <br />() pp Y � ( ) <br />Custody seal(s) intact? N/A f Yes No (See Comments) <br />Trip Blank(s) received Yes ✓ No <br />If Trip Blank was supplied by CAS, record serial # -TB- <br />Temperature of sample(s)/cooler 3 °C Temp Blank?(9 o N (Circle One) <br />Voa's Marked Preserved? Yes j No Filled Properly? Yes V No (See Comments) <br />Preserved Bottles Requiring pH check(s)? Yes Appropriate Preservation? Yes V/ No <br />i <br />RUSH Turn around time? Yes Notified Date & Time <br />Short Hold -Time Analysis (check all that apply) <br />1 ASAP Res Cl_ D.O Flash Diss S2- Ferrous Fe F&P <br />24HR pH Odor Cr+6 <br />48HR BOD Color MBAS Nitrate V <br />Nitrite O-PO4 Sett Sol Turbidity <br />72HR Vapors <br />e-- <br />jJ <br />Notified EU ? Date & Time (V C) <br />Container(s) received and their preservative(s): <br />9- 3 -A.orv, voA (PdL> <br />NO <br />Comments <br />qu <br />Initials, Date, Time✓t' ���4,1 CA -0 rAsr_forms\cooler.doc Rev. 2/25/02 <br />