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ACZ Labomrorits. Inc. • • <br />•-- 30100 Downhill Dave <br />Steamboat Springs. CO 30137 <br /> <br />J/ SAMPLE RECEIPT FORM <br />CLIENT: ~iy~-~~//~Ll,.+,~ DATE <br />PROJECT #: ~-~ ~~b Page 1 of? <br /> <br />/ /~ <br />1) Does this project require special handling procedures such as CLP protocol? YES NO <br />2j Are the custody seals on the cooler intact'? YES NO <br />3) Arz the custody seals on the sample containers intact? YES NO <br />~l) Is there a Chain of Custody (COC), or other directivz shipping papers present'? NO <br />~) Is the COC complzce? <br />Reliryuished? Yzs No Requested Analysis? Yes No ~ NO <br />6) Is the COC in agreement with the samples received? <br /># of Samples: Yes No _ Sample 1D: Yes No <br />Matrix: Yes No # of Containers: Yes No ~ NO <br />7) Is there enough sample for all requested analysis? E NO <br />3) Are all samples within holding limes for requested analysis? NO <br />9) Were all sample containers received intact'? NO <br />10) Are samples requiring no headspace, headspace tree? YES NO <br />! 1) Do the samples require a Foriegn Soils Permit Label or quarantine? YES <br />121 Do samples require special disposaVhold considerations'? <br />Non-Hazardous: Yzs No Hazardous: Yes No Hold: <br />months <br />Describe "NO" items (zxcept #I, 11, R 12): <br /> <br /> <br />R{as the client contacted' Yes No <br />If yes: Date: Name of person contacted: <br />Actions taken or client instructions: <br /> <br /> <br />Signature: <br />FRMQA01 1.01.97.01 <br />