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RFSH-SO W-93 -0003
Revision 5
Figure 1 _
SAMPLE CHECK-IN LIST
OateMme Received: nn `^ SG#:
b /^; ^nns^^
Work Order Number. 5^ ^ w tk i.^ tJLE'
Shipping Container 10: Chain of Custody -616
1. Custody Seals on shipping container irdact? Yes t /No (1
2. Custody Seals dated and signed? Yes l7 No (1
3. Chain-of-Custody record present? C Yes "b ( I
4. Cooler temperature
5. Vermiculite/packing mate ri als is Wet I! D ry ( -r'
6. Number of samples in shipping container:
7. Sample holding times exceeded? Yes ( ] Vo [ }
6.
10.
Sam s have:
tae hazard labels
^tody
seals _appropriate sample labels
9. Samples are:
in good condi tion leaking
broken _have air bubbles
Where any anomalies iden tifi ed in sample receipt? Yes (] No [,
11. Desc ription of aromalies (include sample num bers):
Sample Custodian/Laborato ry: ^jL 3/y1 ^J(Jjr`Z,/,/e:
Telephoned
IA
pp
C-1 03