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' CHROIVI, LA-Bj INC. <br /> SATNIPLE RECEIPT CHECKLIST <br /> Client Name f gee Date/Time Rece, reg <br /> ' <br /> / 4� /�r Y—�J Daae / Time project Rece, red by <br /> 23 <br /> Peference/subm R 5Da7z) Carrier name <br /> ' Checkl s 1 d !� Z/Q Loggea in by <br /> by / c Initials / Date <br /> signature / Dace Matra : b�L <br /> Shipping container in good condition' NA Yes No <br /> Custody seals present on shipping container' Intact Broken Yes No <br /> ' Custodv seals on sample bottles' Intact Broken Yes No <br /> ' Chain of custody present' Yes / No <br /> Chain of custody signed when relinquzshea and received' Yes `� Ne <br /> Chain of custoay agrees with sample labels? Yes v/No <br /> 1 Samples in proper container/bottle' Yes ✓ No <br /> samples intact' Yes �No <br /> sufficient sample volume for incicated test" Yes Nc <br /> VOA vials have zero headsn_ ace' NA Yes No <br /> Trip Blank received? NA v Yes No <br /> All samples rereived within holding time' Yes �No <br /> a�t <br /> Container temprrture? — <br /> pH upon rece=pt _pH ad3ustea Check performed by NA <br /> ' Any NO response must be detailed in the comments section below If items are not <br /> applicable, they should be marked. NA <br /> ' Client contacted' Bate contacted' <br /> Person contacted' Contacted by; <br /> Regarding' <br /> ' Comments <br /> Corrective Acton <br /> SMPLRECO CK <br /> 1 <br />