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SGS Accutest Sample Receipt Summary <br /> Job Number: D81617 Client: CEMEX Project: LYONS QUARRY TR 15 KILN BAGHOUSES DUST <br /> Date/Time Received: 4/12/2016 9:50:00 AM Delivery Method: Airbill Ws: fxe <br /> Cooler Temps(Initial/Adjusted): #1:(20.4/20.4): <br /> Cooler Security Y or N Y or N Sample Integrity-Documentation _Y or N <br /> 1.Custody Seals Present: ® ❑ 3.COC Present: ® ❑ 1.Sample labels present on bottles: © ❑ <br /> 2.Custody Seals Intact: R ❑ 4.Smpl Dates/Time OK ® ❑ 1-12.Container labeling complete: 0 <br /> agree: <br /> 3.Sample container label/COC a ElCooler Temperature Y or N p g 0 .a <br /> 1.Temp criteria achieved: ® ❑ Sample Integrity-Condition Y or N <br /> 2.Cooler temp verification: I Gun; ❑ <br /> 1.Sample recvd within HT: <br /> 3.Cooler media: Ice(Bag) <br /> 2.All containers accounted for: ® ❑ <br /> 4.No.Coolers: 1 <br /> 3.Condition of sample: Intact <br /> Quality Control Preservation Y or N NIA <br /> Sample Integrity-Instructions Y or N NIA <br /> 1.Trip Blank present/cooler: ❑ ❑ lid 1.Analysis requested is clear: ® ❑ <br /> 2.Trip Blank listed on COC: ❑ ❑ ® 2.Bottles received for unspecified tests ❑ R <br /> 3.Samples preserved properly: © ❑ 3.Sufficient volume recvd for analysis: ® ❑ <br /> 4.VOCs headspace free: ❑ ❑ ® 4.Compositing instructions clear: ❑ ❑ <br /> 5.Filtering instructions clear: ❑ ❑ <br /> Comments <br /> D81617: Chain of Custody <br /> Page 2 of 2 <br /> SG46 C T S <br /> Is�s�4- ACUET <br /> D81617 <br />