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SAMPLE RECEIPT FORM <br />z11r r <br />Service Request No: P070 c! `�C b Client: S H*.A/ <br />R Sample(s) delivered by: Client CAS Emp After Hours DHL <br />Golden State Overnight Fed X UPS J 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—7 No (See Comments) <br />Custody seal(s) intact? N/A Yes No (See Comments) <br />Trip Blank(s) received Yes ✓ No <br />Trip Blank was supplied by CAS Yes No <br />Record serial 4 -TB- 1 <br />Temperature of sample(s)/cooler °C Temp Blank? Y N ircle 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 />Y <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 <br />Nitrite O-PO4 Sett Sol Turbidity <br />72HR Vapors <br />Notified, Date & Time <br />Container(s) received and their preservative(s): <br />q0 D <br />Comments i <br />Initials, Date, Time Lt— 4& �� �� �i GASM0\L0GF0RMS\C00LER.D0C <br />