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AC2 t~e«.t«i.>; ~ ~ • <br />sn.oo tb...~nv ta;v. • <br /><._~ ~„„p, co sate <br /> <br />j~ SAMPLE RECEIPT FORM <br />CLIENT: lICA~ ~C~ <br />PROJECT K: ~~UL (!7o/Y n~ r,L({ <br /> <br />DATE ~ d Page 1 a~C 2 <br /> <br />7 k y$ <br />1) Does this project require special handling ptottdures such as CLP protocol? YES NO <br />2) Arc the custody seals on the cooler intact? YES NO <br />3) Are the custody seals on the sample containers intact? . i~ YES NO <br />s) Is there a Chain oC Custody (COC), ar other directive shipping papers present? ~ NO <br />S) Is the COC rnmplete? ~ <br />Relinquished? Ya No RoquestedAnalysis7 Yes_ <br />No ~-~ NO <br />6) Is the COC in agreement with the samples rtxived? <br />N of Samples: Yes _ No _ Sample ID: Yes _ <br />Matris: Yes No N oCContainers: Ya <br />No _ <br />No NO <br />7) Is there enough sample Cor all requested analysis? NO <br />8) Are all samples within holding times Cor requested analysis? NO <br />9) Were all sample containers received intact? NO <br />It)) Are samples requiring no headspace, headspace Cree? A YES NO <br />11) Do the samples require a Foriegn Soils Permit Label or quarantine? YES <br />12) Do samples «quire special disposaVhold cotuiderations? <br />Non-Hazardous: Yes No Hazardous: Yes No <br />Hald: <br />months <br />Describe "NO' items (except ~1, l I, & 1?): <br /> <br /> <br />Waz the client contacted? Yes No <br />If y es: Date: Name of person contacted <br />Actions taken or client instructions: <br />: <br /> <br /> <br />Signature: <br />Received <br />NOV 3 0 19,48 <br />Dura~~Fea~~ t~Qrtott.ots~.a <br />Division of Minrtr~s 8 ~ <br />bDY <br />