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- CHROMALAB, INC. <br /> SAMPLE RECEIPT CHECKLIST t7 <br /> Received / l <br /> Dara/Time ReceD tell / Time <br /> Client Name <br /> Received by <br /> Project <br /> �' �i.� Carrier name <br /> Reference 9 — 3 � � 2 7 <br /> %• •��7 / �: Logged in by , /> Initials Dare <br /> Checkl ��pl ed l ,F <br /> `W byr �' Matrix ' <br /> S gnature Data <br /> • - NA— Yes — No <br /> two Shipping container in good condition? Broken — Yes No____ <br /> Custody seals present on _uhipping'container7 Intact <br /> WW Intact-- <br /> Broken Yes_ � No <br /> Custody seals on sample bottles? / <br /> Yes. <br /> Chain of custody present? / <br /> " Yes <br /> Chain of custody signed when relinquished and received? <br /> Yea_ NO <br /> — <br /> chain oif custody agrees with sampl.$ labals? <br /> r.+ Yes No <br /> Samples in proper container/bottle? <br /> ' YeoNo <br /> Samples intact? Yes No,____ <br /> • Sufficient sample volume for• indicated test? <br /> NAZ Yes_____ N°— <br /> v0A vialsr have zero headspace? <br /> NA Yes_ � No <br /> Trip Blank received? Yes No <br /> All samples recaived w MiLn holding time?- <br /> container tempnrntura? NA� <br /> pH upon receipt <br /> . 0 adjutited Check performed by: <br /> Any t2 response must, be detailed in the comments section below. If items are not <br /> applicable; they should be marked NA. <br /> Date contacted? <br /> Client contacted? <br /> Person contacted? <br /> Contacted by7 <br /> Regarding? <br /> Comments$ <br /> r <br /> Corrective Actions <br /> 1 <br />