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Rev.02B Date 09f21 <br /> S unS tar Receiving Form 001 A <br /> Laboratories, Inc. <br /> plWDIMG QL:ALri r ANALrrICAl,Unvwvs HATvw*nG <br /> SAMPLE RECEIVING REVIEW SHEET <br /> Batch/Work Order#: -1?_319 110 <br /> Client blame: �i rY4 r,- Project: r.+tioo� Fl z <br /> Delivered by: ❑ Client ❑SunStar Courier 9GLS ❑ FedF.x ❑ Other <br /> I f Courier, Received by: Date/Time Courier <br /> Received: <br /> Lab Received by: i <br /> Date/Time Lab <br /> y>IS Received: -7- <br /> Total number of coolers received: Thermometer ID: SC-1 Calibration due : 812123 <br /> Temperature: Cooler#1 °C+1-the CF(+0.1°C) = °C corrected temperature <br /> Temperature: Cooler#2 °C+1-the CF(+0.1°C) = °C corrected temperature <br /> Temperature: Cooler#3 °C+1-the CF(+f1.1°C) = °C corrected temperature <br /> Temperature criteria=c 6°C <br /> Within criteria. ❑Yes ❑Nn NIA <br /> no frozen containers) <br /> If NO: <br /> Samples received on ice? Dyes ❑ <br /> Complete Non-Conformance Sheet <br /> If on ice,samples received same day ❑Yes 3 Acceptable []No 4 <br /> collected? Com lete Non-Conform nee Sheet <br /> Custody seals intact on cooler/sample 91yes ❑No* A <br /> Sample containers intact [ Yes []No* <br /> Sample labels match Chain of Custody 1Ds [ Yes []No* <br /> Total number of containers received match COC [ Yes ❑No* <br /> Proper containers received for analyses requested on CDC des ❑No* <br /> Proper preservative indicated on COClcontainers for analyses requested ❑Yes ❑No* [✓�N/A <br /> Complete shipment received in good condition with correct temperatures, <br /> containers, labels,volumes preservatives and within method specified dyes ❑No* <br /> holding times <br /> *Complete Non-Conformance Receiving Sheet if checked Cooler/Sample Review- initials and date: '--)T 7. j 13 <br /> Comments: <br /> Page 1 of 1 <br /> Drive M Lake Forest. C. Page 23 of 33 <br />