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BC LABORATORIES INC. SAMPLE RECEIPT FORM Rev. No. 12 11s/E4/08 Page <br />Submission #: 09-110 <br />SHIPPING INFORMATION SHIPPING CONTAINER <br />Federal Express 0 UPS 0 Hand Delivery 0 Ice Chest None 0 <br />BC Lab Field ServIce,,X Other 0 (Specify)_ Box 0 Other 0 (Specify) <br />Refrigerant: Ice If Blue Ice 0 None 11 Other 0 Comments: <br />Custody SealsIce Chest bC Containers , - 0 None Comments: <br />Fintact? Yes Q-N-Q 0 1 intact? Yes- 0 No 11 <br />All samples received? Yes 0 No 0 All samples containers Intact? Yes 0 No El Description(s) match COC? Yes 0 No 0 <br />'210 <br />COC Received Emissivity: O 5 Container: Thermometer ID.—ManaD Date1Tlme-wk,-,-1v-q <br />0 YES 0 NO Temperature: A 1t2- "C 1 1 C A c Analyst Init <br />SAMPL S <br />SAMPLE CONTAINERS 2 3 4 6 6 7 <br />07 GENERAL MI NERAU GENERAL PHYSICAL <br />PT PE UNPRESERVED <br />OT INORGANIC CHEMICAL METALS <br />PT INORGANIC CHEMICAL METALS <br />PT CYANIDE 32 <br />PT NITROGEN FORMS <br />PT TOTAL SULFIDE <br />2o7- NITRATE / NITRITE <br />PT TOTAL ORGANIC CARBON <br />PT TOX <br />PT CHEMICAL OXYGEN DEMAND <br />PtA PHENOLICS <br />40ml VOA VIAL TRAVEL BLANK <br />40n1 VOA VIAL t I 1--A <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 508/608/8080 <br />OT EPA 515.1181 50 <br />OT EPA 525 <br />OT EPA 525 TRAVEL BLANK <br />100ml EPA 547 <br />100ml EPA 531.1 <br />OT EPA 548 <br />gT EPA 549 <br />OT EPA 632 <br />OT EPA 8015M <br />OT AMBER <br />8 OZ. JAR <br />32 OZ. JAR <br />SOIL SLEEVE <br />PCB VLll. <br />PLASTIC BAG <br />FERROUS MON <br />ENCORE <br />Comments: <br />Sample Numbering Completed By: Date/Time: <br />A = Actual I C = Corrected IH- <br />U=SkwpacilLAEk_DOCSWORMS%SAMRFC2-WPDI <br />11 <br />