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• °.rr 1.J0°fa0°r1Ca, loC <br />7W000OnOhiYthne • • <br />Saambot$pmip.CO ~Wt7 <br />Pa®e 2 of 2 <br />SAMPLE RECEIPT FORM <br />CLIENT: ,VAS DATE 7 - ~ - a ~ <br />PROTECT ~i [. 1i3(4 _ ~ ~ ~ - ANALYST: <br />TEMPERATURE VERIFICATION SAMPLE CI~CK (°C) <br />CONTAINER TEI~ (°C~ RAD <br />- • ID 2° to 6" pRRv <br /> G ~ / . ~ !6 Q [f container rrdioactiviry is <br /> ~!- Q ~ > 25 µR/hr then each sample <br /> tut be serceaed. <br /> <br />PRESERVATION CI-TECK (pI-I) 8c RADIOACTIVITY SCREEN <br />SAMPLE R <br />c2 G <br />c1 Y YG <br /><2 <'? B BG O T P RAD <br /><2 <2 <~ > 12 > l2 uR/Iv <br /> v Fa / <br />2 / F /' ~ <br /> /' F' / <br /> F <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />INTERNAL COMMENTS: t <br /> <br /> <br /> <br />REPORT COMMENTS: <br /> <br />FRMQA01lA1.97.0i <br />~~~ 23 <br />