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ADZ Laboratories,Inc. ADZ Laboratories,Inc. <br /> Page 1 of 2 ACZ LABORATORIES,INC. Page 2 of 2 <br /> SAMPLE RECEIPT FORM SAMPLE RECEIPT FORM <br /> CLIENT: �..�'1r DATE L CLIENT: �=T�}jr(f DATE <br /> PROJECT N: <br /> PROJECT N: ANALYST: <br /> I) Does this project require special handling procedures such as CLP protocol? NA YES NO <br /> 21 Ate the custody sob on the cooler Intact? N YES NO TEMPERATURE VERIFICATION SAMPLE CI IECK VC) <br /> J) Are the custody seals on the sample containers Intact? YES NU <br /> COOLER TEMP(-C) <br /> 4) Is there a Chain of Custody(COC),or other directive shipping papers present? ES NO ID 21 to 61 <br /> S) Is the CDC complete? YES NO t <br /> Relinquished?Yes_ NO— Requested Analysis?Yes_ No_ <br /> 6) Is the COC in agreement with the samples received? YES NO <br /> N of samples:Yes_ No_ Sample ID:Yes_ No_ <br /> Matrix:Yes_ No_ N of containers:Yes_ No_ <br /> 7) Is there enough sample for all requested analysis? NO <br /> 6) Are PRESERVATION CHECK(pH) <br /> all samples within holding times for requested analysis? g NO <br /> 9) Were all sample containers received intact? NO SAMPLE R G Y YG B BG O T P <br /> 10) Are samples requiring no hesdspace,headspace Ilee? N YES NO <2 <2 <2 <2 <2 <2 <2 >12 >12 <br /> 11) Do the samples require a Foriegn Soils Permit Label or quarantine? YES <br /> 12) Do samples require special disposal/hold considerations? <br /> Non-Hazardous:Yes No Hazardous:Yet_ No_C---- Itold: months "0 ✓ <br /> v ✓ v <br /> Describe"NO"items(except N1.11.A 12): s <br /> Was the client contacted? Yes_ No_ <br /> • <br /> If yes: Date: Name of person contacted: <br /> Actions taken or client instructions: <br /> COMMENTS: <br /> Signaturr. Date: S <br /> FRMQA011.10.95.01 <br /> FRMQA011.10.95.01 <br /> 'l <br />