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I(IFF RECEIVER <br /> Analvtical u.c SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: 7 9 Z`j q Date: 0 Zs <br /> Project ID: _► V L Sfl e _ lQ 1 P O n <br /> Method of Receipt: Courier\ EJ Over-the-counter hipper <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? % Ces ❑No Dated? Yes F1No <br /> Is sampler name legibly indicated on COC? Yes Opqo <br /> Is analysis or hold requested for all samples Wyes ❑No <br /> Is the turnaround time indicated on COC? Yes ❑No <br /> Is COC free of whiteout and uninitiated cross-outs? Yes ❑No,Whiteout 0:1,Cross-outs <br /> Sample Inspection <br /> Coolant PresentYes ❑No includes water) g,�s(Q� $Z1 <br /> Temperature°C Therm. ID# =t2 -5 Initial-0 7Z Date/Tim ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken of present <br /> Do containers match COC? rl�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 Wo <br /> Are any sample containers broken,leaking or damaged? ❑YesNo <br /> Are preservatives indicated? Wes,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? Yes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes I&No <br /> Receipt Det ils VOA Matrix Container type OA #of containers received—L7— <br /> Matrix <br /> eceivedMatrix Container type #of containers received <br /> Matrix Container type #of containers rec ived <br /> Date and Time Sample Put into Temp Storage Date: C)gZS I 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? Yes [ No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(sn Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? es ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sKnple container(s) nN <br /> n Both E]Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? , Yes o ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample containers On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? s No ❑N/A <br /> COMMENTS: <br /> Wold_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 13 of 14 Page 12 of 12 <br />