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KIFFO RECEIVER <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: 7 Wo'Z_6Date: C 201 I <br /> Project ID: NSlie­ 91 Dn�t <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? Intact E]Broken F]Not present Z N/A <br /> Is COC Signed by Relinquisher? ®Yes ❑No Dated? )<Yes ❑No <br /> Is sampler name legibly indicated on COC? ❑Yes M 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 XLNo,Cross-outs <br /> Sample Inspection <br /> Coolant Present: ZYes E]No(includes water) <br /> Temperature°C 5J_ herm. ID# die— I Initial Date/Time QZCU/%J A-4 ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken ®Not present <br /> Do containers match COC? [SYes ❑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 ®,No <br /> Are preservatives indicated? Yes,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 wA Container type_ #of containers received- <br /> Matrix <br /> eceivedMatrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: t9zol 1 ( Time: J 2© <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample containe (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 E]Not indicated <br /> If project ID is listed on both COC and containers,do they all match? Yes �No E]N/A <br /> Are the sample collection dates indicated: ❑On COC E]On same container(s) On Both E]Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? MYes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) JSOn 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 9 of 9 <br /> Page 9 of 10 02/08/2011 <br />