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K FFOAnalvtical LLC <br />SRG#: <br />Project ID: <br />SAMPLE RECEIPT CHECKLIST <br />'31577 Date: C,>&e7 i3' t Z <br />W� Okt7% , n , <br />RECEIVER <br />Initials <br />Method of Receipt: LJ Courier <br />LJ Over-the-counter <br />)Ohipper <br />COC Inspection <br />Temperature °C Therm. ID# ,( - 4; Initial_ Date/Time_ <br />Are there custody seals on sample containers? <br />Is COC present? <br />Yes <br />InIntact <br />❑ No <br />Custody seals on shipping container? <br />Are any sample containers broken, leaking or damaged? <br />❑ Broken,KrNot present ❑ N/A <br />Is COC Signed by Relinquisher? KYes ❑ No <br />Dated? ,K Yes <br />❑ No <br />Is sampler name legibly indicated on COC? <br />❑ Yes <br />K;4o <br />Is analysis or hold requested for all samples? <br />KYes <br />❑ No <br />Is the turnaround time indicated on COC? <br />RrYes <br />❑ No <br />Is COC free of whiteout and uninitialed cross -outs? <br />es <br />❑ No, Whiteout ❑ No, Cross -outs <br />Sample Inspection <br />Coolant Present: XYes ❑ No (includes water) <br />Temperature °C Therm. ID# ,( - 4; Initial_ Date/Time_ <br />Are there custody seals on sample containers? <br />❑ Intact <br />Do containers match COC? gYes ❑ No ❑ No, COC lists absent sample(s) <br />Are there samples matrices other than soil, water, air or carbon? <br />❑ Yes <br />Are any sample containers broken, leaking or damaged? <br />❑ Yes <br />Are preservatives indicated? ❑ Yes, on sample containers <br />❑ Yes, on COC <br />Are preservatives correct for analyses requested? <br />❑ Yes <br />Are samples within holding time for analyses requested? <br />Yes <br />Are the correct sample containers used for the analyses requested? <br />Yes <br />Is there sufficient sample to perform testing? <br />Yes <br />Does any sample contain product, have strong odor or are otherwise suspected <br />to be hot? <br />Receipt Details <br />0600312- 105,e ❑ N/A <br />❑ Broken 'Not present <br />❑ No, Extra sample(s) present <br />XNo <br />❑ Not indicated J N/A <br />F] No &N/A <br />❑ No <br />❑ No <br />❑ No <br />❑ Yes ANo <br />MatrixC,� Container type S I -e2 # of containers received_ <br />Matrix Container type # of containers received <br />Matrix Container type # of containers received <br />Date and Time Sample Put into Temp Storage Date: 'D(D SL-. Time: 11a7-) <br />uicklo <br />Are the Sample ID's indicated: ❑ On COC ❑ On sample container(s) 2JOn Both ❑ Not indicated <br />If Sample ID's are listed on both COC and containers, do they all match? Yes ❑ No ❑ N/A <br />Is the Project ID indicated: ❑ On COC ❑ On sample container(s) I On Both ❑ Not indicated <br />If project ID is listed on both COC and containers, do they all match? Yes ❑ No ❑ N/A <br />Are the sample collection dates indicated: ❑ On COC ❑ On sample container(s) NOn Both ❑ Not indicated <br />If collection dates are listed on both COC and containers, do they all match? Yes ❑ No ❑ N/A <br />Are the sample collection times indicated: ❑ On COC ❑ On sample contaider(s) [j� On Both ❑ Not indicated <br />If collection times are listed on both COC and containers, do they all match? [),Yes ❑ No ❑ N/A <br />COMMENTS: <br />O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br />Page 8 of 8 <br />