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KI FF RECEIVER <br /> Analvtical uc SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: Date: 060412 <br /> Project 1D: J2sOi O s4yc"c-&"' -7WM.✓lac <br /> Method of Receipt: K Courier ❑Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? Intact ❑Broken ❑Not present N/A <br /> Is COC Signed by Relinquisher? [KYes ❑No Dated? Yes ❑No <br /> Is sampler name legibly indicated on COC? [gYes ❑No <br /> Is analysis or hold requested for all samples? X Yes ❑No <br /> Is the turnaround time indicated on COC? ®Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? 5Q Yes ❑No, Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: Yes No(includes water) <br /> Temperature'C J,q Therm. ID# S — Initial 7ZI� Date/Time 06011 14Z� ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken KNot present <br /> Do containers match COC? C&Yes ❑No ❑No,COC lists absent sample(s) ❑No,Extra sample(s)present <br /> Are there samples matrices other than soil,water,air or carbon? ❑Yes §No No <br /> Are any sample containers broken, leaking or damaged? E]Yes <br /> Are preservatives indicated? ❑Yes,on sample containers ❑Yes,on COC ❑Not indicated N/A <br /> Are preservatives correct for analyses requested? ❑Yes ❑No N/A <br /> Are samples within holding time for analyses requested? X]Yes ❑No <br /> Are the correct sample containers used for the analyses requested? XYes ❑No <br /> Is there sufficient sample to perform testing? Yes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes X]No <br /> Receipt Details <br /> Matrixes Container type S1 #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: p( i'Z Time: 114Z& <br /> Quickloiz <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) X On 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) On Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? RYes No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? Nyes No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) ®On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? Yes ❑No E]N/A <br /> COMMENTS: <br /> rjr <br /> ern 1 C ?9�6 <br /> EK'VIRONM� <br /> HEALTH r$;TA ' <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 28 of 28 <br />