NYC 9/11 Public Portal Document
PSC Analytical Services
Sample Receipt Checklist
Is
Client Name JLC ENVIRONMENTAL CONS Date and Time Receive 4/1/2003 9:25:00 AM
Work Order Numbe R03040013 Received by TMH*
Checklist completed by \t Reviewed by W-
Initials
Y*/•0,3
Date
S~ature Da
Matrix: Carrier name _F
Shipping container/cooler In good condition? Yes No ❑ Not Presen ❑
Custody seals intact on shippping container/cooler? Yes ❑ No ❑ Not Presen
Custody seals intact on sample bottles? Yes ❑ No ❑ Not Presen I I
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 0 No ❑
Sufficient sample volume for indicated test? Yes No Li
samples received within holding time? Yes ❑~ No ❑
I
Container/Temp Blank temperature In compliance? Yes No ❑
Water - VOA vials have zero headspace? No VOA vials submitted (] Yes ❑ No ❑
Water - pH acceptable upon receipt? Yes No ❑
Adjusted? Checked b
Any No and/or NA (not applicable) response must be detailed in the comments section be
-- — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — — -
Client contacted Date contacted: Person contacted
Contacted by: Regarding:
Comments:
Corrective Action
NYC-WTC 000132245
OCR can misread numbers and units. Confirm readings against the page image before using them.