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Cr >ea..,,t 1;1 w.p <br />LJuisvaIe CO <br />Project# 31103 <br />Sample Receipt Form <br />Sample #• <br />Date: (LxtI D <br />Sales Were• <br />;'f. Shipped Hand Delivered Messengered (circle one) <br />-- -- - -- tes: <br />5. Sample Received Broken or Leaking Y <br />Notes: <br />6. Received Within Holding Times <br />Notes: <br />7. Aeration necessary <br />Notes. <br />8. Sample Received at Temperature between O-6 C . <br />Notes: <br />9 Description of Sample (Color, Odor, and /or Presence of Particulate Matter). <br />eff: /6 r1 � � c�r va t 1 <br />Eff <br />Rec' <br />rec'g <br />Temp DO (mg/_) DO ( %sat) <br />L y <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 />H <br />Cond <br />Initials. <br />Y <br />Y N c' Nom' <br />Y CN <br />N `_l <br />N <br />( Y <br />E ffective i N ember ,:008 <br />Ambient t •Cbilled . (circle one) <br />3. Chilled to Ship <br />Notes: <br />7 Wet Ice Blue Ice (circle one) <br />4. Cooler Received Broken or Leaking Y ; N NA <br />Notes: <br />N <br />NA <br />NA <br />N NA <br />p <br />p <br />Aeration <br />Time DO (m DO (Mat) <br />H <br />