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KIFFORECEIVER <br /> Analvtical u.c SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: Date: NOW) <br /> Project ID: IVBP-ipa <br /> Method of Receipt: Courier n Over-the-counter Enhipper <br /> COC Inspection <br /> Is COC present? Kyes No <br /> Custody seals on shipping container? ZJntact Broken ❑Not present ❑N/A <br /> Is COC Signed by Relinquisher? ElYes ❑No Dated? Yes No <br /> Is sampler name legibly indicated on COC? ❑Yes No <br /> Is analysis or hold requested for all samples ®Yes No <br /> Is the turnaround time indicated on COC? I I Yes No <br /> Is COC free of whiteout and uninitialed cross-outs? Yes No,Whiteout -]No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: Yes ❑No(includes water <br /> Temperature°C 3- Therm.ID# T 12-S Initial Date/Time 0q0 1C) o_57Z ❑N/A <br /> Are there custody seals on sample containers? ❑Intact Broken S Not present <br /> Do containers match COC? ®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? SLYes,on sample containers ❑Yes,on COC Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? R1 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? Yes No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes 4No <br /> Receipt De ils p <br /> Matrix Container type N O j 1 #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> _ <br /> Date and Time Sample Put into Temp Storage Date: Qq Q 910 Time: 1 O <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample con m r(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) a On Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? A Yes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On safnple container(s) On 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 coner(s) On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? �9 Yes No ❑N/A l <br /> COMMENTS: e-,; ! 07 <br /> O:\old_eftamprecTormASample Receipt Checklist rev 051409.doc <br /> Page 14 of 15 Page 13 of 13 <br />