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THE SEACREST GROUP <br /> 325 INTERLOCKEN PARKWAY <br /> SUITE 205 <br /> BROOMFIELD, COLORADO 80021 <br /> SAMPLE RECEIPT FORM ' <br /> Protect Number 3%/3s <br /> Date/Initlale 9/2 r�44' ei 3 <br /> SamplwWers: <br /> 1. Sht Hand Delivered or Messenger <br /> OTES: <br /> 2. Alrbill Present Y NA <br /> NOTES: <br /> 3. Ambient or chi'l Ice r Blue Ice Temp. ' pH <br /> Eta 6.6 • 5.2 <br /> NOTES: ice anf�.el�cd <br /> 4. Cooler received Broken/Leaking Y N <br /> NOTES: <br /> 6. Sample Received Broken/Leaking (Improperly Sealed) <br /> Y (io <br /> NOTES: <br /> 8. Samples Properly Preserved (chilled to eC) AD N <br /> NOTES: <br /> 7. Received within Holding Times N <br /> NOTES: <br /> COC Tape Was: <br /> 1. Present on Outer Package Y V� <br /> 2. Unbroken on Outer Package Y N <br /> 3. Present on Sample Y <br /> 4. Unbroken on Sample Y N <br /> COC Record Was:1. Present Upon Receipt of Sample N <br />