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Figure 1<br />

SAMPLE CCK-IN LIST<br />

DateMme Received: l^ ^0^^^ SG#: &ZQQ7,-^<br />

RFSH-SOW-93 -0003<br />

Revision 5<br />

Work Order Number. 0 ^3c^^ 0^ SAF #: -<br />

ShippingContainerID: -0 ChainofCustody# ' gW^J^^v<br />

1. Custody Seals on shipping container intact? -<br />

Yes [ 1<br />

2. Custody Seats dated and signed? Yes No [ )<br />

f t^^<br />

3. Chain-of-Custody record present? Yes Cij /No [ )<br />

4. Cooler temperature<br />

^O<br />

5. Vermiculitefpaci ing mate ri<br />

als is Wet [ ] Dr/—{ ^^^^<br />

6. Number of samples in shipping container.<br />

(<br />

r'<br />

7. Sample ho&q times exceeded? Yes [ ] No (^<br />

8. Samples have:<br />

--^Zape<br />

custody seals<br />

9. Same are:<br />

in good condition<br />

brdm<br />

hazard labels<br />

appropriate sample labels<br />

leaking<br />

have air bubbles<br />

10. Where any anoma lies identified in sample receipt? Yes [ I No Cl/<br />

11. Descrip tion of anomalies (include sample numbers):<br />

Sample CustodiargUbo<br />

Telephoned To:<br />

7<br />

o^<br />

/<br />

Date: ^O/C)

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