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ACiZ laborataiea, Inc. • • <br />70400 Downhill Dri~'e <br />S~cam6oLL Sprinpp, CO 80487 <br /> <br />SAMPLE RECEIPT FORM <br />CL~NT: U ak DATE <br />PROrECr#: LZl'`~3`L Page 1 of 2 <br /> <br />t 2. ~ qg <br />1) Does this project require special handling procedures such as CLP protocol? YES NO <br />2) Are the custody seals on the cooler intaM? YES NO <br />3) Are the custody seals on the sample rnntainers intact? ~ NO <br />4) Is there a Chain of Custody (COC), or other directive shipping papers present? ~~ NO <br />5) Is the COC rnmplete? <br />Relinquished? Yes No Requested Analysis? Yes No SJ NO <br />6) Is the COC in agreement with [he samples received? <br /># of Samples: Yes _ No _ Sample ID: Yes _ No <br />Matrix: Yes No # of Containers: Yes No S NO <br />7) Is there enough sample for all requested analysis? S NO <br />8) Are all samples within holding times for requested analysis? S NO <br />9) Were all sample containers received intact? S NO <br />10) Are samples requiring no headspace, headspace free? NA YES NO <br />11) Do the samples require a Foriegn Soils Permit Label or quarantine? YES NO <br />l2) Do samples require special disposal hold considerations? <br />Non-Hazardous: Yes No Hazardous: Yes No Hold: <br />months <br />Describe "NO" items (except #l, l 1, & 12): <br /> <br /> <br />Was the client contacted? Yes No <br />>f yes: Date: Name of person contacted: <br />Actions taken or client inswctions: <br /> <br /> <br />Signature: <br />FantQnot t.ot.m.a <br />