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KIFFO RECEIVER <br /> r <br /> Analvtical «c SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: 4�� � 7 Date: 0 Z 12 <br /> Project ID: �l e �.t pevo <br /> Method of Receipt: 0 Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? ®Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ®Not present ❑N/A <br /> Is COC Signed by Relinquisher? Kl Yes ❑No Dated? YC Yes ❑No <br /> Is sampler name legibly indicated on COC? Yes ❑No <br /> Is analysis or hold requested for all samples Yes ❑No <br /> Is the turnaround time indicated on COC? Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? IZ Yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: ®Yes ❑No(includes water) �1 <br /> Temperature°C2_2 Therm. ID# 1(2-S Initial Date/Time O Z Z Z l 7 ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken ®Not present <br /> Do containers match COC? ([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 ;Z No <br /> Are any sample containers broken, leaking or damaged? ❑Yes FktNo <br /> Are preservatives indicated? KYes,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 (<No <br /> Receipt Details <br /> Matrix Container typee_ #of containers received 2 0 <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: Q L 2 Z \ Time: f <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? N 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? KYes NNo ❑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? VYes NNo ❑N/A <br /> COMMENTS: <br /> 0:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 14 of 14 <br /> Page 15 of 16 03/01/2011 <br />