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Rev.02S Date 08/21 <br /> SSIInSta Receiving Form 001 A <br /> Laboratories, Inc. <br /> pwm <br /> Goon AKNXrWAL KAM* = <br /> SAMPLE RECEIVING REVIEW SHEET <br /> SatchlWork Order#: TZ361zl� <br /> Client Name: _D.r*" r Project: L A <br /> Delivered by: ❑ Client ❑ SunStar Courier N1 GLS ❑ FedEx ❑Other <br /> If Courier, Received by: Date/Time Courier <br /> Received: <br /> Lab Received by: Date/Time Lab <br /> 0AVt Received: <br /> Total number of coolers received: N 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+/-the CF(+0.1°C) = °C corrected temperature <br /> Temperature criteria=c b°C Within criteria? ❑Yes ❑No UNIA <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 4 Acceptable [--]No 4 <br /> collected? Complete Non-Conformance Sheet <br /> Custody seals intact on cooler/sample [ yes [—]No* ❑NIA <br /> Sample containers intact &1Yes ❑No* <br /> Sample labels match Chain of Custody IDs 74Yes ❑No* <br /> Total number of containers received match COC ®Yes ❑No* <br /> Proper containers received for analyses requested on COC Yes ❑No* <br /> Proper preservative indicated on COC/containers for analyses requested ❑Yes ❑No* NIA <br /> Complete shipment received in good condition with correct temperatures, <br /> containers, labels,volumes preservatives and within method specified ® Yes ❑No* <br /> holding times <br /> *Complete Non-Conformance Receiving Sheet if checked Cooler/Sample Review-Initials and date: SQ q-f 0. Z :— <br /> Comments: <br /> Page I of <br /> Page 15 of 18 <br />