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FMAX-SM02 <br />Rev. 3 <br />Appendix 2 <br />SAMPLE RECEIPT FORM 1 <br />Type of Delivery <br />Delivered B /Airbill ECNQ2,,,.? <br />❑ <br />❑ Damaged <br />[Z .S ficient <br />El 3 <br />❑ Cooler 7 -El <br />❑ Cooler 11 <br />❑ EMAX Courier <br />Rece .ient <br />. uw_c;� <br />❑ Client Delivery <br />Date <br />0dParty <br />Time <br />COC Inspection <br />L - wnt Name Sampler Name ©-Sampling Date/Time/Location <br />F-4*ddress ❑ Courier Signature/Date/Time D -Analysis Required <br />[ lient PM/FC [ TAT E4 -Matrix <br />.-Tel #/Fax # Sample ID <br />©Preservative (if any) <br />Safety Issues ne ❑ High Concentrations expected ❑ Superfund Site Samples <br />Comments: n Rar1 irrPPnlnn Rpnnirpri <br />ContainerCooler <br />Condition <br />Packaging <br />Temperatures <br />Comments: <br />Packaging Inspection <br />❑ Box <br />❑ Custody Seal - <br />❑Bubble Pack *ElStyrofoam <br />-t ooler 1 . y L C_ ❑ <br />Cooler 2 <br />Cooler 5 ❑ Cooler 6 <br />ElCooler 9 _ ❑ Cooler 10 <br />❑ <br />❑ Damaged <br />[Z .S ficient <br />El 3 <br />❑ Cooler 7 -El <br />❑ Cooler 11 <br />❑ <br />❑ <br />-� <br />❑ Cooler 4 <br />Cooler 8 <br />❑ Cooler 12 <br />LSCID <br />Client ID Discrepancy <br />Corrective Action <br />LZ:)Ulu : Lap Sam le t_;ontalner lu <br />REVIEWS <br />Sample Labeling <br />Date <br />PM i _ <br />Date a 20 106 <br />