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<br />J d.1 O111W: ~:~ ".a.. l'U i0a ti' <br /> <br />/~~ •~'/~ SAMPLE RECEIPT FORM <br />CLIENT ~`~ ~1/"'~ <br />PROJECT ~: ~~ ~ ~ ~ /~ <br /> <br />DATE ~ ~ Page 1 of 2 <br /> <br />~ ~~ <br />I) Dozs this project require special handling procedures such as CLP protocol? A YES NO <br />?) Are the custody seals on the cooler intact? ~ YES NO <br />;) Are the custody seals on the sample containers intact? YES NO <br />~) Is there a Cham of Custody (COC), or o[her directive shipping papers preseni? 1' NO <br />~) Is the COC complete? <br />Relinquished? Yes No _ Requested ' ~~s _ No <br />_ NO <br />6) Is the COC in agreement with the samples received? i- ~1Q~ <br /># of Samples: Yes No _ A~~ L.l:`YFs No <br />Ntatrix: Yes _ No _ # ot~Container ~ l~i~~ No <br />_ <br />_ YFS~` NO <br />7) Is [here enough sample for all requested analysis? \,~,v\StO~~ E NO <br />3) Are all samples within holding times for requested analysis? NO <br />9) \Vzre all sample containers received intact? NO <br />Ip) Are samples requiring no hzadspace, headspace free? A YES NO <br />I I) Do the samples require a Foriegn Soils Perrrtit Label or quarantine? YES <br />I?) Do samples require special disposaUhold considerations? <br />Non-Hazardous: Yes No Hazardous: Yes No <br />Hold: months <br />Describe "NO" items (except #I, 11, ~C 1?): <br /> <br /> <br />Was [hz clien[ contacted'? Yes No <br />If yes: Dale: Name of person contacted: <br />Actions talon or client instrucnons: <br /> <br /> <br />Signature: ~~ <br />FRb1QA011.01.97 04 <br />