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KI FF RECEIVER <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST <br /> SRG#: Date: O� <br /> Project ID: lie "D <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? ,�Yes ❑No <br /> Custody seals on shipping container? ❑intact Broken ❑Not present .fN/A <br /> Is COC Signed by Relinquisher? 'Yes ❑No Dated? ❑Yes �No <br /> Is sampler name legibly indicated on COC? ZYes ❑No <br /> Is analysis or hold requested for all samples? , Yes ❑No <br /> Is the turnaround time indicated on COC? ZYes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs ❑Yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: 2J Yes No(includes water) <br /> Temperature°C Therm. ID# (� Initial Date/Time QCo u� 2- [:]N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Z Not present <br /> Do containers match COC? O 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 <br /> Are any sample containers broken,leaking or damaged? ❑Yes �No <br /> Are preservatives indicated? ❑Yes,on sample containers ❑Yes,on COC ❑Not indicated ON/A <br /> Are preservatives correct for analyses requested? ❑Yes ❑No N/A <br /> Are samples within holding time for analyses requested? Yes ❑No <br /> Are the correct sample containers used for the analyses requested? Yes ❑No <br /> Is there sufficient sample to perform testing? 9 Yes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes E)60 <br /> Receipt Details <br /> Matrix_ Container type ��'y�' #of containers received d� <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: 6 ( L Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) ®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 NNo ❑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? KYes FNo ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) No <br /> n Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? &Yes ❑N/A <br /> COMMENTS: C e On i f!Med ie J an 574L 4700 <br /> FEB 16 <br /> ENVIRONMENTAL <br /> F{EpITF' <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 32 of 32 <br />