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:~ICZr.r.~,m.b, ta. • • <br />aaoo o:rv. <br />s ~. co eoaa~ <br /> <br />SAMPLE RECEIPT FORM <br />CLIENT: ~z ~ tMa., ~, t= -~ ~, Co ~. <br />PROJECT #: RuL L {~Y~ v-t u1 C <br /> <br />DATE 7 l Page 1 oft <br />/ <br />r o 198 <br />1) Does tdis project require spxial dandling procedures sued as CLP protocol? YES NO <br />2) Are the custody seals on the cooler intact? ~J' YES NO <br />3) Are the custody seals on the sample containers intact? YES NO <br />~) Is there a Chain of Custody (COC), or other directive shipping papers present? ~ NO <br />5) Is the COC complete? _ <br />Relingtrished7 Yes _ No _ Rogtrested Analysis? Yes _ <br />No NO <br />6) Is the COC in agreement with the samples received? <br /># of Samples: Yes _ No _ Sample ID: Yes _ <br />Matrix: Yes No # of Containers: Yes <br />No <br />No NO <br />'n Is there enough sample for all requested analysis? NO <br />8) Are all samples within holding times for requested analysis? NO <br />9) Were all sample containers received intact? NO <br />Ill) Are samples requiring no headspace, deadspace free? YES NO <br />l l) Do the samples require a Foriegn Soils Permit Label or quarantine? YES <br />12) Do samples require special disposaUhald considerations? <br />Non-Hazardous: Yes No Hazardous: Yes No <br />Hold: months <br />Describe "NO" items (except #1, il, & 12): <br /> <br /> <br />Was the client contacted? Yes No <br />If yes: Date: Name of person wntacted: <br />Actions taken or client instructions: <br /> <br /> <br /> Signature: <br />wwQaou.otsra <br />