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0 <br /> ADZ Laboratories,Inc. • AG Z Laboratories,Inc. <br /> Page I of 2 ACZ LABORATORIES,INC. Page 2 of <br /> SAMPLE RECEIPT FORM SAMPLE RECEIPT FORM <br /> CLIENT: C DATE 7 l¢ CLIENT: 1. imax DATE <br /> PROJECT q: (.(p j _ PROJECT N: L/0_3 t/ —73 ANALYST: <br /> 1) Does this project require special handling procedures such as CLP protocol? NA YES O <br /> 2) Are the custody seals on the cooler intact? NA NO TEMPERATURE VERIFICATION SAMPLE CHECK(°C) <br /> 3) Are the custody seals on the sample containers intact? YES NO COOLER TEMP(°C) <br /> 4) Is there a Chain of Custody(COC),or other directive shipping papers present? NO ID 2°to 6° <br /> 5).Is the COC complete? NO c -ersl` .0 <br /> Relinquished?Yes_ No_ Requested Analysis?Yes— No— <br /> 6) Is the COC in agreement with the samples received? 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 PRESERVATION CHECK(pH) <br /> 8) Are all samples within holding times for requested analysis? NO <br /> 9) Were all sample containers received intact? eT4 NO SAMPLE R G Y YG B BG O T P <br /> 10) Are samples requiring no headspace,headspace free? N YES NO <2 Q <2 <2 <2 <2 <2 >12 >12 <br /> 11) Do the samples require a Foriegn Soils Permit Label or quarantine? YES N -01 t/ <br /> 12) Do samples require special disposal/hold considerations? Z- ✓ <br /> Non-Hazardous:Yes No Hazardous:Yes No Hold: months <br /> Describe"NO"items(except 41,11,&12): <br /> Was the client contacted? Yes No_ <br /> Ifyes: Date_ Name ofperson contacted: <br /> Actions taken or client instructions: <br /> G COMMENTS: <br /> 7Signature: Date: O <br /> FRMQA011.10.95.01 FRMQA011.10.95 t <br />