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KIFFORL-7- 9- <br /> ECEIVER <br /> Analvtica► u.c SAMPLE RECEIPT CHECKLISTInitials <br /> SRG#: 1+S Date: O (J l7J <br /> Project ID: <br /> Method of Receipt: LJ Courier 0 Over-the-counter ipper <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? ntact ❑Broken ❑Not present ❑N/A <br /> Is COC Signed by Relinquisher? 4Yes ❑No Dated? Yes E]No <br /> Is sampler name legibly indicated on OC? ❑Yes WNo <br /> Is analysis or hold requested for all samples Yes ❑No <br /> Is the turnaround time indicated on COC? NYes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? 9yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: Yes ❑No(includes water) /r`7 rn' <br /> Temperature°C �' Therm. ID# =2--S Initial � —Date/Time Og�� I ON/ <br /> Are there custody seals on sample containers? ❑Intact ❑Broken of present <br /> Do containers match COC? Yes ❑No ❑No,COC lists absent sample(s) ❑No,Extra sa ple(s)present <br /> Are there samples matrices other Nan soil,water, air or carbon? ❑Yes No <br /> Are any sample containers broken, leaking or damaged? ❑Yes No <br /> Are preservatives indicated? g9yes,on sample containers ❑Yes,on COC Not indicated [_ N/A <br /> Are preservatives correct for analyses requested? 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? 0 Yes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? Yes No <br /> Receipt Details LQW-08161110 <br /> Matrix_ Container type \1D #of containers receivedt�_ l <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers rec r%ed <br /> Date and Time Sample Put into Temp Storage Date: 00 gt � 0 Time: O� <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 ❑No ❑N/A <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: ❑On COC ❑On sample 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 container(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 /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 11 of 12 Page 10 of 10 <br />