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ICI FF RECEIVER <br /> Analvtical Lac SAMPLE RE E �T CHECKLIST Initis <br /> SRG#: Date: 07?wa <br /> Project ID: - <br /> Method of Receipt: Courier Over-the-counter ipper <br /> COC Inspection <br /> Is COC present? 0 Yes ❑No <br /> Custody seals on shipping container? 21niact ❑Broken ❑Not present ❑N/A <br /> Is COC Signed by Relinquisher? ❑'Yes ❑No Dated? 2-yes ❑No <br /> Is sampler name legibly indicated on COC? ❑Yes PK0 <br /> Is analysis or hold requested for all samples 121'es ❑No <br /> Is the turnaround time indicated on COC? [2-y-es ❑No <br /> Is COC free of whiteout and uninitiated cross-outs? e-y-es ❑No, Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: PTyes ❑No(includes water) <br /> Temperature°C 3 s L Therm. ID# fZ—<_ Initial _ Date/Times��2 i y ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken 2-11�ot present <br /> Do containers match COC? �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 2-no <br /> Are any sample containers broken, leak' or damaged? ❑Yes 940 <br /> Are preservatives indicated? 2 Y eS,on sample containers ❑Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? Oles ❑No ❑N/A <br /> Are samples within holding time for analyses requested? O*es ❑No <br /> Are the correct sample containers used for the analyses requested? [les ❑No <br /> Is there sufficient sample to perform testing? 21vres ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes 0 No <br /> Receipt Det <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: o 724id Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) ,eCin 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 contai er(s) On Both ❑Not indicated <br /> If project ID is listed on both COC and containers, do they all match? ,p'es No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) On Both E]Not indicated <br /> ,z <br /> If collection dates are listed on both COC and containers, do they all match? Yes FNo ❑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 H No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Fortns\Sample Receipt Checklist rev 051409.doc <br /> Page 12 of 14 ppyV01410 <br />