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' fICZ I~ba Jlar;4,t~. <br />)(IJpO po..nhill Driw <br />Si~rnbut Spnngf. CO 80487 <br /> <br /> <br /> <br />' <br />c SAMPLE RECEIPT FORM <br />~IENT: l ~P C ~ / <br />o~cr #: L ~ 9 s~ z <br /> <br />DATE ~ /2-~ Page 1 of 2 <br /> <br />/4 8 <br />I ) Does [his project require special handling procedures such as CLP protocol? ~A YES NO <br /> Are the custody seats on the cooler intact? ~ YES NO <br /> Arc the custody seals on the sample containers intact? ~t YES NO <br /> is there a Chain of Cttstody (COC), or other directive shipping papers present? NO <br /> Is the COC complete? ~ ~ <br />RelinquishedT Yes _ No _ Requested AnalysisT Yes _ <br />No _ NO <br /> Is the COC in agreement with the samples received2 <br /># of Samples: Yes _ No _ Sample lD: Yes _ <br />Matri:c: Yes No #otContainers: Yes <br />No _ <br />No ES ~ NO <br /> is there enough sample for all requested analysis? YES NO <br />Are all samples within holding times Cor requested analysis? NO <br />Were all sample containers received intact? NO <br />l0) Are samples «quiring no headspace, headspace free? YES NO <br />Do the samples require a Foriegn Soils Permit Label or quarantineT YES NO <br />l?) Do samples require special disposaVhold considerations? <br />Non-Hazardous: Yes No Hazardous: Yu No <br />Hold: months <br />Describe "NO" items (except #l, l 1, & 1Z): <br /> <br /> <br />`ls the client contagedT Yes _ No _ <br />i' If ~ es Date: Name of person contacted: <br />.Actions taken or client instructions: <br /> <br /> <br />1, Signature: l~ <br /> <br /> <br />t: ttuQ.w u.a t?~.a <br />