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Figu re 1<br />

RFSH-SOW-93-0003<br />

Revision 5<br />

SAMPLE CHECK-IN LIST<br />

S<br />

Date^me Received: , ^I ^ l^^l / SG# l l^ ^l ^— 7<br />

1<br />

Work Order Number. SAF #: f5 1 — -<br />

Shipping Container ID: Chain of Custody if<br />

1. Custody Seals on shipping contakw intact? Yes [ 1,140' [ 1<br />

2. Custody Seals dated and signed? Yes [I No ( ]<br />

3. Chain-of-C ustody record preserd? Yes _ ,] No ( ]<br />

4. Cooler temperature<br />

5.<br />

/` e<br />

"7<br />

VermicuWpacicing mate ri<br />

als is Wet [ [ C ry (^<br />

6. Number of samples in shipping cmtainer. c<br />

7. Sample holding ti<br />

mes exceeded? Yes [ ] No [ ]<br />

8. Sa les have:<br />

Pe<br />

/ custody seals<br />

hazard labels<br />

_appropriate sample labels<br />

9. —8mptes are:<br />

in good condition leaking<br />

broken have air bubbles<br />

10. Where any anomalies identified in sample receipt? Yes [ ] No<br />

11. Desc ri ption of anomalies (include sample numbe rs):<br />

Sample Custodian/Laborato ry:<br />

Telephoned To: On.<br />

14<br />

C11i

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