NYC 9/11 Public Portal Document
PSC Analytical Services
Sample Receipt Checklist
Client Name JLC ENVIRONMENTAL CONS Date and Time Receive 4/1/2003 9:25:00 AM
Work Order Numbe R03040014 Received by TMH*
Checklist completed by
Signature
4 ¼ Date
Reviewed by
initials Date
Matrix: Carrier name Fed
Shipping container/cooler In good condition? Yes No ❑ Not Presen ❑
Custody seals intact on shippping container/cooler? Yes ❑ No ❑ Not Presen Se
Custody seals Intact on sample bottles? Yes ❑ No ❑ Not Presen W
Chain of custody present? Yes No ❑
Chain of custody signed when relinquished and received? Yes No ❑
Chain of custody agrees with sample labels? Yes No ❑
Samples in proper container/bottle? Yes (] No ❑
Sample containers intact? Yes No ❑
Sufficient sample volume for indicated test? Yes No ❑
W II samples received within holding time?
Container/Temp Blank temperature In compliance?
Yes W
Yes 0
No ❑
No ❑
Water - VOA vials have zero headspace? No VOA vials submitted Yes ❑ No ❑
Water - pH acceptable upon receipt? Yes Se No ❑
Adjusted? Checked b
Any No and/or NA (not applicable) response must be detailed In the comments section be
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Client contacted Date contacted: Person contacted
Contacted by: Regarding:
Comments:
Corrective Action
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NYC-WTC 000132223
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