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JAN-20-99 WED 10 26 Ri] <br />ACZ ,.~~,;~, t..., <br />~oaoo uow,h~n a;~ <br />AteamboLL Springs, CO AOJ87 <br />Dt1G~URANGO FIELD OFFICE <br />FAH N0, 9747+5104 <br />P, 05 <br /> <br />SAMPLE RECEIPT FORM <br />CUF,NT: Q a DATE Page 1 of 2 <br /> <br />t z f f <br />1) Does this project require special handling procedures such as CLP protocol? YES NO <br />2) Arc the custody seals on tJre cooler intact? YES NO <br />3) Arc the custody seals on the sample Containers intact? a NO <br />~) 1s there a Chain of Custody (COC), or other directive shipping papers present? ~E'S1 NO <br />5) Is the COC complete? <br />Rclinquishcd7 Yes Na Requested AnafysisT Yes _ No ~ NO <br />li) is the COC in agreement with the sampics rcoeivod7 <br /># of Samples: Ycs ^ No _ Samp[c ID: Yes _____ No _ <br />Matrix: Yes No # of Containers: Yes No S NO <br />7) Is there enough sample for all requested analysis? ~ NO <br />8) Arc all samples within holding times for tegttested analysis? S NO <br />9) Wcre all sample containers received intact? S NO <br />10} Are samples requiring no hcadspaoc, hcadspace free? NA YES NO <br />11) Do the samples require a Foriegn Soils Permit Label or quarantine? YES NO <br />12) Do samples require special disposaUhold considerations? <br />Non-Hvardous: Yes No Hazardous: Yes No Hold: <br />months <br />Describe 'NO" items (except #1, 11, & 12): <br /> <br /> <br />Was the client contacted? Yes No <br />1f yes: Date: Name of person cAntactcd: <br />Actions Wkcn or client instructions: <br /> <br /> <br /> Signalurc: ~ <br />atutQnou.ot.rr.a <br />