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KIFFORWEIVER Analytical ctcSAMPLE RE IPT CHECKLIST SRG#: """" Date: Project ID: (/�.A(t !till Method of Receipt: Courier Over-the-counter Shipper COC Inspection Is COC present? Yes ❑No Custody seals on shipping container? Intact ❑Broken Not present ON/A Is COC Signed by Relinquisher? RYes ❑No Dated? Yes ❑No Is sampler name legibly indicated on COC`? R1 Yes ❑No Is analysis or hold requested for all samples IV Yes ❑No Is the turnaround time indicated on COC? Yes ❑No Is COC free of whiteout and uninitialed cross-outs? ❑Yes ❑No, W -out f No,Cross-outs Sample Inspection Coolant Present Yes No(includes water), Tem rature C Therm.ID# 2- initial J DatelTime12 1 y EJ N/A Are there custody seals on sample containers? ❑Intact ❑Brokeft Not present Do containers match COC? ❑Yes 14 No []No.COC lists absent sample(s) ❑No,Extr i sample(s)present Are there samples matrices other than soil,water,air or carbon? ❑Yes No Are any sample containers broken,leaking or damaged? ❑Yes No Are preservatives indicated? Yes,on sample containers ❑Yes,on COC ❑Not indic ated ❑NIA Are 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? [KYes ❑No Is there sufficient sample to perform testing? J}Yes ❑No Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑ es X No Receipt D is Matrix Container type Pq S kkA #of containers received Matrixes Container type 2,Std Alf 0o1V #of containers received_ Matrix Container type #of containers received Date and Time Sample Put into Temp Storage Date: O q-1 Z(C7 Time: Com{5-2- Ouickloe Are the Sample ID's indicated: ❑On COC ❑On sample container(s) ,R On Bo ❑Not indicated If Sample ID's are listed on both CqC and containers,do they all match? s ❑No ❑N/A Is the Project ID indicated: MQ U, On COC ❑On sample containers) T<bTl Both ❑ of indicated If project ID is listed on both COC and containers,do they all match? Vyes o ❑ IA Are the sample collection dates indicated: ❑On COC ❑On sarriple container(s) ;ROn BOO []Not indicated If collection dates are listed on both COC and containers,do they all match? XYes ❑No ❑N/A Are the sample collection times indicated: ❑On COC ❑On sample container(s) Z On Bo ❑Not indicated If collection times are listed on both COC and containers,do they all match? ®Yes []No E]NIA COMMENTS: k to6ec.5 &,a UO ,J$ AA $ O l_e5c-- v A- 77: s -A 0 i 2 in X)o IST- oZ jS on62,11. 41015 MID IbZ- O:bld_edlsamprcc\Forms�S=p1c Reccipt Checklist rev 051409.dm Page 7 of 7