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BC LABORATORIES INC. <br />SAMPLE RECEIPT FORM Rev. No. 12 0w L" Page -L Of <br />Submission #: 0 <br />SHIPPING INFORMATION SHIPPING CONTAINER <br />Federal Express 0 UPS 0 Hand Delivery 0 Ice Chestd None 0 <br />BC Lab Field Service zo Other 0 (Specify) Box 0 Other 0 (Specify)_ <br />Refrigerant: Ice Blue Ice 0 None 0 Other 0 Comments: <br />Refrigerant: <br />Custody Seals e Chest d St 0 <br />r,"n(ntact? <br />ContaintIs ;0 None f6 Comments: <br />Containers <br />�No <br />t Y N <br />Intact? Yes, Q <br />No <br />All samples received? Yes No <br />-COC Received <br />0 1 <br />'Z -YES ®N® <br />All samples containers intact? Yes No Description(s) match COC? YeSX No 0 <br />Ali <br />2Z 1D <br />Emissivity: QR�' , Container: Q4:::� Thermometer ID.—Man1t) Daternrne%J%I�W <br />Temperature: A -C Analyst snit jw*�, <br />To, -C) CD C I p C C) - 3, <br />SAMPLE CONTAINERS <br />SAMPL I IMRFRS <br />1 2 3 1 4 5 6 7 s 10 <br />L <br />GENERAL <br />QT GENERAL MINERALI GEN PHYSICAL f: - <br />'A'j GENERA PHYSICAL <br />31 "EP <br />PT PE UNPRESERVFD <br />R EDCHEMICAL <br />P, <br />. <br />I METALS <br />H MICAL ET LS <br />M <br />OT INORGANIC _MC LM <br />T LS <br />L ME T <br />PT INORGANIC CHEMICAL ALS <br />P <br />PT CYANIDE <br />12 <br />JA <br />NITROGEN FORMS <br />PPT <br />P. <br />PT TOTAL SULFIDE <br />qIT I <br />2o7- NITRATE I NITRITE <br />CARBON <br />PT TOTALORGANIC CARBON <br />Y6 <br />PT TOX <br />PT CHEMICAL OXYGEN DEMAND <br />OXYGEN <br />PtA PHENOLICS <br />40.1 VOA VIAL TRAVEL BLANK <br />40ml VOA VIAL <br />OT EPA 413.1,413.2,418.1 <br />PT ODOR <br />RADIOLOGICAL <br />BACTERIOLOGICAL <br />40 ml VOA VIAL- 504 <br />OT EPA 509/608/8090 <br />OT EPA 515.1/8150 <br />T E <br />OT EPA 525 <br />T E P <br />- <br />EPA 525 TRAVEL BLANK <br />T E P <br />0 <br />100m) EPA 547 <br />I <br />0 0 <br />100mi EPA 531.1 <br />r1K BY <br />P <br />OT EPA 548 <br />T E <br />EPA0 <br />QT EPA 549 <br />T -P <br />[320Z <br />TI' <br />EP <br />QT EPA 632 <br />• EP <br />OT EPA 8015M <br />OT AMBER <br />• Al, <br />r <br />I L <br />SOZ <br />8 OZ. JAR <br />Z JAR <br />r16 N N OP <br />SOIL SLEEVE <br />0 a 0 ma <br />PCBVIAL <br />PLASTIC BAG <br />FERROUS IRON <br />IENCORE -- <br />5 <br />Comments: I <br />� <br />Sample Numbering Completed By: Bateffime: -K jH:%DocSxwpquU-Ao S%SAMREC2-WPD1 <br />A = Actual I C = Corrected _DOCSIFORM <br />