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THE SEACREST GROUP <br /> 325 INTERLOCKEN PARKWAY <br /> SUITE 205 <br /> BROOMFIELD, COLORADO 80021 <br /> SAMPLE RECEIPT FORM <br /> Project Number 39q 39 <br /> Date/initlele l 9 y D J <br /> We <br /> . Shipped or and Delivered or Messenger <br /> 2. Alrbili Present N NA <br /> NOTES: <br /> 3. Ambient or illed Ice or Blue Ice Tamp, pH <br /> NOTES: '" Z Vi 5`I J"SSq..7 G 9•z <br /> 4. Cooler received Broken/Leaking Y N <br /> NOTES: <br /> 5. Sample Received Broken/Leaking (Improperly Sealed) <br /> ' Y <br /> NOTES: <br /> S. Samples Properly Preserved (chilled to 4°C) �Y N <br /> NOTES: <br /> 7. Received wRhin Holding Times LY) N <br /> NOTES: <br /> COC Tape Was: <br /> 1. Present on Outer Package Y <br /> 2. Unbroken on Outer Package Y N <br /> 3. Present on Sample Y �N <br /> 4. Unbroken on Sample Y N <br /> COC Record Was: <br /> 1. Present Upon Receipt of Sample ci) N <br />