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SAMPLE RECEIPT FORM <br /> Service Request No: P0700 J7(i Client: <br /> Sample(s) delivered by: Client CAS Emp After Hours <br /> 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 V--'No (See Comments) <br /> Containers supplied b CAS? Yes V'No V--> <br /> -- <br /> Custody <br /> pP Y (See Comments) <br /> Custody seals) intact? N/A � Yes No (See Comments) <br /> Trip Blank(s) received Yes V' No <br /> If Trip Blank was supplied by CAS, record serial # -TB- <br /> Temperature of sample(s)/cooler C�— °C Temp Blank?D N(Circle One) <br /> Voa's Marked Preserved? Yes i No Filled No Properly?? YesV See Comments <br /> P Y ( ) <br /> Preserved Bottles Requiring pH check(s)? Yes Appropriate Preservation? Yes 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 F&P <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_�_�7V / <br /> Container(s) received and their preservative(s): <br /> 57 <br /> 3 0 /1V1:5; C/> <br /> IY5 / �'/V�o <br /> Comments 6P ! 6W )a <br /> Initials, Date, Time /P/,5\sr ormskooler.do <br /> c Rev.2/25/02 <br />