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SAMPLE CONDITION UPON RECEIPT CHECKLIST <br />PROJECT# S0F11.E CLIENT 6rn9nl ,G <br />INITIALS/ <br />DATE: -l4�o <br />If custody seals are present on cooler, are they intact? <br />ldNA 0 YES ❑ NO <br />Cooler/Sample temperature <br />1 oC <br />Thermometer ID: Fluke 96312917 <br />Were samples received on ice/cold packs? <br />Z'YES ❑ NO <br />How did samples arrive? <br />❑ Over the Counter Picked up by F&BI <br />❑ FedEx/UPS/GSO <br />Is there a Chain -of -Custody* (COC)? DYES ❑ NO <br />or other representative documents, letters, and/or shipping memos <br />Initials/ 7V�l <br />Date: sil joY� <br />Number of days samples have been sitting prior to receipt at laboratory 0_ days <br />Are the samples clearly identified? (explain "no" answer below) <br />,YES ❑ NO <br />Were all sample containers received intact (i.e. not broken, <br />leaking etc.)? (explain "no" answer below) <br />YES 0 NO <br />Were appropriate sample containers used? YES <br />❑ NO ❑ Unknown <br />If custody seals are present on samples, are they intact? <br />,d NA 0 YES ❑ NO <br />Are samples requiring no headspace, headspace free? <br />X NA ❑ YES 0 NO <br />Is the following information provided on the COC, <br />and does it match the sample label? <br />(explain "no" answer below) <br />Sample ID's <br />Yes <br />❑ <br />No <br />❑ Not on COC/label <br />Date Sampled <br />Yes <br />❑ <br />No <br />❑ Not on COC/label <br />Time Sampled 11 <br />Yes <br />0 <br />No <br />❑ Not on COC/label <br /># of Containers 11 <br />Yes <br />❑ <br />No <br />Relinquished <br />Yes <br />❑ <br />No <br />Requested analysis <br />Yes <br />❑ <br />On Hold <br />Other comments (use a separate page if needed) <br />Air Samples: Were any additional canisters/tubes received? )2(NA ❑ YES ❑ NO <br />Number of unused T015 canisters** <br />"Fill out Green manifolds billing sheet <br />Number of unused T017 tubes <br />FRIEDMAN & BRUYA, INC./FORMS/CHECKIN/SAMPLECONDITION.doc <br />Rev. 05/01/24 <br />