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Ci <br />r <br />SAMPLE RECEIPT FORM <br />Service Request No: P070 ® it % Client: C57H4W <br />Sam 1 <br />p e(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 />Con in <br />to er(s) supplied by CAS. Yes 1iNo (See Comments) <br />Custody seal(s) intact? N/A Yes No (See Comments) <br />Trip Blank(s) received Yes No i <br />If Trip Blank was supplied by CAS, record serial # -TB- <br />Temperature of sample(s)/cooler °C Temp Blank6-Y r N (Circle One) <br />Voa's Marked Preserved? Yes 1 -'No Filled Properly? Yes iNo See Comments) <br />Appropriate <br />( ts) <br />Preserved Bottles Requiring pH check(s)? Yes � Preservation? Yesi'/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 />24HR pH Odor Cr+6 <br />48HR BOD Color MBAS Nitrate V <br />Nitrite O-PO4 Sett Sol Turbidity <br />72HR 'Vapors <br />NotifiedDate & Time,1)0-107 <br />Container(s) received and their preservative(s): <br />Comments <br />Initials, Date, Time <br />( / T sMO\LOGFORMS\COOLER.DOC <br />