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SAMPLE RECEIPT FORM <br /> CONTROL NO 96BII rn DATE 02-Z -96 <br /> �C CLIENT w CA-t a TIME <br /> z PROJECT IV z c # r o cX 6 6 S Tp Cie T-0 N) RECIPIENT p <br /> n SAMPLE TRANSPORTATION TO CKY LABORATORY BY ON DATE AT IME FROM SITE/CO COMMENTS <br /> PICKED-UP BY CKY COURIER <br /> DELIVERED BY CLIENT l <br /> SHIPPED/AIRBILL NO - mP'p* 3011!t6.§'3 4$!3 R¢(L.LI <br /> SAMPLE BATCH PACKAGING/SEALING UPON RECEIPT NO CONTAINER INTACTDAMAGED NOT SEALED SEALED <br /> i- CONTAINER INSIDE TEMPERATURE 'Z C CUSTODY SEAL/OTHER SEAL LOCATION NUMBER <br /> COOLER PACKAGING TYPE SUFFICIENCY INTACT DAMAGED <br /> BOX INSULATION NAME <br /> 0 _OTHER. ICE/COOLANT )ZMuLfl— DATE <br /> ,..# PACKING MATERIAL j31r+.�3PAVeRIt- TIME <br /> SAMPLE DOCUMENTATION/CHAIN-OF-CUSTODY COC NONE HANDCARRIED ENCLOSED FAXED SEALED <br /> m SAMPLE LOG-IN' CRITERIA COMMENTS DISCREPANCY <br /> a• SAMPLE CUSTODY SEAL EVERY SAMPLE IJ CAM <br /> a CONTAINER TYPE/MATERIAL APPROPRIATE <br /> w SAMPLE AMOUNT ENOUGH <br /> v <br /> eo SAMPLE PRESERVATION/HOLDING TIME SUFFICIENT <br /> HEADSPACE/BUBBLES ZERO/NONE <br /> SAMPLE LABEL INFORMATION SUFFICIENT <br /> CHAIN-OF-CUSTODY INFORMATION SUFFICIENT <br /> ISAMPLE INFO SAMPLE ID DATE TIME SIGNATURE ANALYSES PRESERVATIVE CONTAINER l <br /> INDIViDUAL SAMPLE CONTAINER NONE /PLASTIC BAG CAN OTHER SPECIE Lt ,+ SEALED <br /> M SAMPLE NUMBER CLIENT ID DISCREPANCY ACTION <br /> o <br /> 16F Urc <br /> Ln <br /> o -n rox <br /> w <br /> m <br /> w <br /> r+ <br /> oho <br /> opo / t <br /> �e <br /> w <br /> r+ <br /> Q <br /> o, CLIENT SERVICES COPY RECEIVED BY DATETIME <br /> N <br /> �D <br /> O <br /> 00 <br /> M <br />