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KIFFO RECEIVER <br /> Analvtical u.c SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: --7�7 1' Date: 01 Z56 <br /> Project ID: '1 e..514.sz- ( VOA <br /> Method of Receipt: 0 Courier Over-the-counter Egshipper <br /> COC Inspection <br /> Is COC present? KYes ❑No <br /> Custody seals on shipping container? gintact ❑Broken ❑Not present ❑N/A <br /> Is COC Signed by Relinquisher? ®Yes ❑No Dated? Yes ❑No <br /> Is sampler name legibly indicated on COC? ❑Yes gNo <br /> Is analysis or hold requested for all samples , Yes ❑No <br /> Is the turnaround time indicated on COC? 10 Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? 10Yes ❑No, Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: 'S Yes ❑No(includes water) <br /> Temperature°C 5 .d Therm. ID# ZP-- Initial Wl ) Date/Time Cf7 2-7'10&2 ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Not present <br /> Do containers match COC? U 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 Q No <br /> Are any sample containers broken, leaking or damaged? ❑Yes -nNo <br /> Are preservatives indicated? Yes,on sample containers ❑Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? g Yes ❑No ❑N/A <br /> Are samples within holding time for analyses requested? JOYes ❑No <br /> Are the correct sample containers used for the analyses requested? ja Yes ❑No <br /> Is there sufficient sample to perform testing? 59 Yes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes Sallo <br /> Receipt Details <br /> Matrix-JA Container type QoA #of containers received (-e <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: bgaID Time:_ 0224_ <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 o ❑NIA <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? ` Yes ❑No ❑N/A <br /> Are the sample collection dates indicated: E]On COC E]On samp a container(s) On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? KYes No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample contai r(s) On Both ❑Not indicated <br /> If collection times are listed on both COC and containers, do they all match? Yes ❑No ❑N/A <br /> COMMENTS: <br /> Wold ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 10 of 12 Page 9 of 9 <br />