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ACZ t~ruor;~+. ~. • M <br />~aaoo Do..,,n;u o~;~~ <br />s~v,,,~ s~~, co soaav <br />RECFIVen <br />F <br />SAMPLE RECEIPT FORM E6 2 2 1999 <br />n ~~, ~ EFISGA DEP.T~ <br />CLIEN'T': //v ~ DA <br />PROJECT #: L Z Z /r/ `1 Page 1 of 2 <br /> <br />q <br />(~ C <br />1) Dces this project require special handling procedures such as CLP protocol? A YES NO <br />2) Are the custody seals on the cooler intact? NA '~,$~ 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 />i) Is the COC complete? <br />Relinquished? Yes No Requested Analysis? Yes _ No NO <br />6) Is the COC in agreement with the samples received? <br /># of Samples: Yes _ No _ Sample m: Yes _ No _ <br />~Iatrir: Yes _ No _ # of Containers: Yes _ No _ S NO <br />7) Is there enough sample for all requested analysis? ;]LIaB~ NO <br />3) Are all samples within holding times for requested analysis? 'f}35~, NO <br />9) Were all sample containers received intact? ~' NO <br />IO) Are samples requiring na headspace, headspace free? YES NO <br />11) Do the samples require a Foriegn Soils Permit Label or quarantine? YES ~~ <br />12) Do samples require special disposal hold considerations? <br />Non-Hazardous: Yes No Hazardous: Yes No Hold: <br />months <br />Describe "NO" items (except #l, 11, &. l2): <br /> <br /> <br />Was the client contacted? Yes Na <br />[f yes: Date: Name of person contacted: <br />Actions taken or client instructions: <br /> <br /> <br />Signature: <br />rxuQaott.ot.s~.os <br />