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t f'IC J~Xv!~~J i IaROU~ <br />326 INTERLOC}LEN PARKWAY <br />sutTE zoo <br />BROOMFIEt-D, COLORADO 80021 <br />SAMPLE RECEIPT FORM <br />Project Numt3er ~ c's Z y S <br />Date/Infllale 6 ~ ~ '~- w-' <br />Samples~lNere: <br />1. ShlppedJar Hand Delivered or Messenger <br />`"NOTES: ~' <br />2. A1rb111 Present Y <br />NOTES: <br />3. Ambient or chflled ~ Ice cr Blua ice Temp <br />_,., ~: <br />-~ ` --~ <br />NOTES: ; _ 7 ,~ <br />i <br />4. Cooler received Broken/Leaking Y <br />NOTES: <br />6. Sample Received BrokenJLeaking (Improperly Sealed) <br />Y <br />NOTES: <br />-1 <br />B. Samples Properly Preserved (chilled to A°C) Y ' <br />NOTES: ~- ~~ <br />,11 <br />7. Rece{ved wlthfn Holding Tlmea Y;' <br />NOTES: <br />COC Tape Was: <br />1. Present on Outer Package <br />2. Unbroken on Outer Package <br />3. Present on Sample <br />4. Unbroken on Sample <br />COC Record Was: <br />1. Present Upan Recalpt of Semple <br />~ N ~ NA <br />~_, <br />Y <br />Y <br />Y <br />Y <br />Y i <br />PH <br />'~ z <br />i. 9 <br />N~ <br />~~ <br />N ~ <br />~,. ~ <br />N <br />N <br />;N ~ <br />N <br />N <br />N <br />N <br />