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SeaCrest Group <br />Louisville, 00 <br />Project #: 2 ,\ I ( bg , V <br />Date: t -)72. <br />Sam • ere: <br />Sample Receipt Form <br />Sample #: <br />Initials: <br />1. S 1ppe• Hand Delivered Messengered (circle one) <br />Notes: <br />3. Chilled to Ship <br />Notes: <br />4. Cooler Received Broken or Leaking <br />Notes: <br />5. Sample Received Broken or Leaking <br />Notes: <br />6. Received Within Holding Times / y f N <br />Notes: <br />7. Aeration necessary <br />Notes: <br />8. Sample Received at Temperature between 0-6 . <br />Notes: <br />9. Description of Sample (Color, Odor, and /or Presence of Particulate Matter): <br />eff: C l.v `'l ' <br />rec'g <br />Custody Seals: <br />1. Present on Outer Package <br />2. Unbroken on Outer Package <br />3. Present on Sample <br />4. Unbroken on Sample <br />Custody Documentation: <br />1. Present Upon Receipt of Sample <br />Y <br />Y <br />Y <br />Y <br />C <br />ND <br />N <br />Ambient Chilled ) (circle one) <br />Wet Ice ) Blue- Ice (circle one) <br />Y <br />N <br />rurm 4 42 <br />Effective December 2008 <br />NA <br />NA <br />NA <br />NA <br />