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KI FFLLCO RECEIVER <br /> Analvticai SAMPLE WCEIPT CHECKLIST <br /> SRG#: / 00 Date: 0 <br /> Project ID: � ` � <br /> Method of Receipt: Courier ver-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present [ /A <br /> Is COC Signed by Relinquisher? [. Yes ❑No Dated? 2-les ❑No <br /> Is sampler name legibly indicated on COC? ❑Yes 2-Ko <br /> Is analysis or hold requested for all samples Q I es ❑No <br /> Is the turnaround time indicated on COC? Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? ❑'lames ❑No,Whiteout ❑No, Cross-outs <br /> Sample Inspection <br /> Coolant Present: 2"YesNo(includes water) 636 <br /> oZ`� / <br /> Temperature°C - ( Therm. ID# �� Initial Date/Time 6 ❑N/A <br /> Are there custody seals on sample containe s? ❑Intact ❑Broken ❑-?Qoot present <br /> Do containers match COC? 211' es ❑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 9d10 <br /> Are any sample containers broken,leaking or damaged? ❑Yes PiI4b <br /> Are preservatives indicated? [2-Yes,on sample containers ❑Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? ❑-les ❑No ❑N/A <br /> Are samples within holding time for analyses requested? l'Yes ❑No <br /> Are the correct sample containers used for the analyses requested? &! es ❑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 E -N- <br /> Receipt Det4ils <br /> Matrix Container type #of containers received <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 YO 2—0 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? Wes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) [ n Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? Oyes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) ffOn 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 container(s) ❑'On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? ❑Yes ffKO ❑N/A <br /> COMMENTS milli' t C &L r - �I jLlc <br /> -Jua <br /> P - ©/ •• d f1 Za <br /> u Com <br /> ArL <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 14 of 15 Page 13 of 13 <br />