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Rev. 02C Date 11/23 <br />SS1nS� Receiving Form 001A <br />Laboratories, Inc. <br />F�ovar�+ieo Eetm Ar�urrte u. 3suv Narwwsvrrpn <br />SAMPLE RECEIVING REVIEW SHEET <br />Batch/Work Order #: �_ Vp6 y� / CC '' .' R <br />Client Name: � Prc ject:5q'��''y ST Mwoh " � � ^/ L' V (' [31 Vj <br />Delivered by: ❑ Client ❑ SunStar Courier N GLS ❑ FedEx ❑ Other <br />If Courier, Received by: Date/Time Courier <br />Received: <br />Lab Received by: Date/Time Lab <br />'cam Received: Z • 9 •2 y NZ5 <br />Total number of coolers received: Thermometer ID: SC -1 Calibration due: 11/17/2024 <br />Temperature: Cooler #I y • S °C +/- the CF (+ 0.1 °C) = °C corrected temperature <br />Temperature: Cooler #2 °C +/- the CF (+ 0.1 °C) = °C corrected temperature <br />Temperature: Cooler #3 °C +/- the CF (+ 0.1 °C) = °C corrected temperature <br />Temperature criteria =5 VC Within criteria? &Yes [—]No ❑N/A <br />no frozen containers <br />If NO: <br />Samples received on ice? ❑Yes ❑No 4 <br />Complete Non -Conformance Sheet <br />If on ice, samples received same day ❑Yes --> Acceptable ❑No 4 <br />collected? Complete Non -Conformance Sheet <br />Custody seals intact on cooler/sample <br />Sample containers intact <br />Sample labels match Chain of Custody IDs <br />Total number of containers received match COC <br />Proper containers received for analyses requested on COC <br />Proper preservative indicated on COC/containers for analyses requested <br />Complete shipment received in good condition with correct temperatures, <br />containers, labels, volumes preservatives and within method specified <br />holding times <br />Oyes <br />❑No* ❑N/A <br />Eyes <br />❑No* <br />2'es <br />❑No* <br />KYes <br />❑No* <br />XYes <br />❑No* <br />'Yes <br />❑No* ❑N/A <br />9 Yes ❑No* <br />* Complete Non -Conformance Receiving Sheet if checked Cooler/Sample Review - Initials and date: 1, <br />Comments: <br />Page 1 of <br />