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SAMPLE CONDITION UPON RECEIPT CHECKLIST <br /> INITIALS/ <br /> PROJECT# CLIENT 1(Q, QzV DATE:_ <br /> If custody seals are present on cooler, are they intact? NA ❑ YES ❑ NO <br /> Cooler/Sample temperature -7 °C <br /> Thermometer ID:Fluke 9G312917 <br /> Were samples received on ice/cold packs? ❑ YES 0"NO <br /> How did samples arrive? <br /> Over the Counter ❑ Picked up by F&BI ❑ FedEx/UPS/GSO <br /> Is there a Chain-of-Custody* (COC)? /dYES ❑ NO Initials/ & <br /> *or other representative documents, letters, and/or shipping memos Date: 11 a <br /> Number of days samples have been sitting prior to receipt at laboratory _7431/ _ days <br /> Are the samples clearly identified? (explain"no" answer below) ,DYES ❑ NO <br /> Were all sample containers received intact (i.e. not broken, DYES ❑ NO <br /> leaking etc.)? (explain"no" answer below) <br /> Were appropriate_sample containers used? YES ❑ NO ❑ Unknown <br /> If custody seals are present on samples, are they intact? )2(NA ❑ YES ❑ NO <br /> Are samples requiring no headspace, headspace free? 4 NA ❑ YES ❑ NO <br /> Is the following information provided on the COC, and does it match the sample label? <br /> (explain"no" answer below) <br /> Sample ID's Yes ❑ No ❑ Not on COC/label <br /> Date Sampled I Yes ❑ No ❑ Not on COG/label <br /> Time Sampled E Yes 0 No ❑ Not on COC/label <br /> # of Containers Yes ❑ No <br /> Relinquished M Yes ❑ No <br /> Requested analysis I I Yes ❑ On Hold <br /> Other comments (use a separate page if needed) <br /> Air Samples: Were any additional canisters/tubes received? V/NA ❑ YES ❑ NO <br /> Number of unused T015 canisters Number of unused T017 tubes <br /> FRIEDMAN&BRUYA,INC./FORMS/CHECKIN/SAMPLECONDITION.doc Rev.05/01/24 <br />