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KIFFO R,EcEIIVE,R, Ana►vtical uc SAMPLE RECEIPT CHECKLIST 'Initials SRG#: 'F$ 1 4 I / Date: (�1 Project 1 D: 1'L�St7•'''o S�O�.f/�'�oi'\ 1 e�/'wl.(`h.� I REGEIV D Method of Receipt: XCourier Over-the-counter ❑Shipper FEB 16 2016 COC Inspection Is COC present? [ ,Yes ❑No ENVIRONMENTAL Custody seals on shipping container? ❑Intact ❑Broken ❑N4E0 T$Af)W T Is COC Signed by Relinquisher? KYes ❑No Dated? ®Yes ❑No Is sampler name legibly indicated on COC? ®Yes ❑No Is analysis or hold requested for all samples? ®Yes ❑No Is the turnaround time indicated on COC? ®Yes ❑No Is COC free of whiteout and uninitiated cross-outs? Yes ❑No, Whiteout ❑No,Cross-outs Sample Inspection Coolant Present: Yes No(includes water / Temperature°C .fie Therm. ID#l 3 Initial I—� Date/Time 06/P Z �b3Z ❑N/A Are there custody seals on sample containers? ❑Intact ❑Brok t allot present Do containers match COC? (-Yes ❑No ❑No,COC lists absent sample(s) ❑No, Extra sample(s)present Are there samples matrices other than soil,water,air or carbon? ❑YesNo Are any sample containers broken, leaking or damaged? ❑Yes No Are preservatives indicated? EJYes,on sample containers L]Yes,on COC �Not indicated 0 N/A El preservatives correct for analyses requested? Yes No N/A Are samples within holding time for analyses requested? Yes ❑No Are the correct sample containers used for the analyses requested? Yes ❑No Is there sufficient sample to perform testing? Yes ❑No Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes JXNo Receipt D tails Matrix Container type—S Lo—ewc.— #of containers received �— Matrix Container type #of containers received Matrix Container type #of containers received Date and Time Sample Put into Temp Storage Date: Ob t S/2_— Time: IL 3 5 uicklo Are the Sample ID's indicated: ❑On COC ❑On sample container(s) MOn Both ❑Not indicated If Sample ID's are listed on both COC and containers,do they all match? Yes ❑No ❑N/A Is the Project ID indicated: ❑On COC ❑On sample container(s) On Both ❑Not indicated If project ID is listed on both COC and containers,do they all match? NYeslNo ❑N/A Are the sample collection dates indicated: ❑On COC [—]On sam le container(s) On Both ❑Not indicated If collection dates are listed on both COC and containers,do they all match? CR�Yes ❑No ❑N/A Are the sample collection times indicated: ❑On COC E]On sample contalner(s) NAOn Both E]Not indicated If collection times are listed on both COC and containers,do they all match? Yes No ❑N/A COMMENTS: -b2 I� % i c S 061Z12 45. 54wx I144-e - 7ke- C.0 C t c'c 41 S b6 I S 12 ► L �o r �LM o6 �� f 2 1yQ O:\old_edlsamprec\Forms\Sample Receipt Checklist rev 051409.doc Page 25 of 25