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KIFF RECEIVER <br /> OA <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: 7 6 IS 3 Date: <br /> � I <br /> Project ID: -& ZJ/5 e _ 91'po <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? OYes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present E3 N/A `I <br /> Is COC Signed by Relinquisher? c�Yes ❑No Dated? CR 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? Yes ❑No, Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: 4S-YesNo(includes water) <br /> Temperature°C S • 2_ Therm. ID# -1 Initial OA Date/Time Z N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Not present i <br /> Do containers match COC? t!F!kes ❑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 No <br /> Are any sample containers broken, leaking or damaged? ❑Yes o <br /> Are preservatives indicated? 4Nes, on sample containers ❑Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? es ❑No F-1N/A <br /> Are samples within holding time for analyses requested? Yes ❑No <br /> Are the correct sample containers used for the analyses requested? cKyes ❑No <br /> Is there sufficient sample to perform testing? efElyes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑YesNo <br /> Receipt Details <br /> Matrix 1-120 Container type V6 A #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container type #pf containers received <br /> Date and Time Sample Put into Temp Storage Date:D l Z/ f/ Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) Q]On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? KYes ❑No E]N/A <br /> ❑ <br /> Is the Project ID indicated: ❑On COC On sample container(s) LVOn.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? E[Yes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) 7A'1 On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? FZYes No ❑N/A <br /> COMMENTS: Q; �ycz-7T I,r� Set,wtnl� —0JLCiR-yll���) C�Iu/a z o� Z:. <br /> TJ-aylZI 1&52- <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 20 of 20 <br /> Page 39 of 43 01/31/2011 <br />