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ACZ c~e~.ar;a, ~ <br />30.00 oo.aea ori.e <br />so~rsvt~.w tlo+sr <br /> <br />SAMPLE RECEIPT FORM <br />CL[ENT: ~ SfcCG2 DATE <br />PROJECT ~: t, ~8 1 T 3 <br /> <br />,~ Page 1 of 2 <br /> <br />t( <br />I) Does this project require special handling procedturos such as CLP protocol? YE;i NO <br />2) Are the custody seats on the cooler intatx'! YES NO <br />3) Ate the custody seals on the samplc containers intact? YE5 NO <br />4) Is there a Chain of Custody (COC), or other directive hipping~papers Present? ~ 1P.E5 NO <br />5) [s the COC complete? <br />Relinquished? Yes No Requested Analysis? Yes _ t`fo ~$_ NO <br />~ Is the COC ct agreement with the samples received? <br />At of Samples: Ya , No _ Sample ID: Yes _ No _ <br />Matrix: Yes No p of Containers: Yes No NO <br />7) Is there enough sample for all requested analysis? NO <br />8) Are all samples within holding times for requested analysis? YES NO <br />9) Were all sample containers received intact? ~ NO <br />10) Are samples requiring no headspace, headspace @ee? ~ YES NO <br />I () Da the samples require a Foriegn Soils Permit Label or quarantine? YES ~~ <br />l2) Do samples rcqu've special disposal/hold considerations? <br />Non-Hazardotu: Yes No Hazardous: Yes No Hold: <br />months <br />Destxibc "NO" items (except~l, l 1, & 1?): _ <br /> <br /> <br />Was the client contacted? .Yes No <br />Ifyes: Date: _ Name of person contacted: <br />Actions taken or client instructions: .~, <br /> <br /> _ <br /> Signattue: ~ ~ <br />FQMQApI lAl9T.o4 <br />~~~ 7 <br />