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I(IFF0 RECEIVER <br /> Analytical LLC SAMPLE RECEIPT CHECKLIST 11 _ <br /> SRG#: S Date: 1 ( 7(y <br /> Project ID: Gt✓ 2 <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? EzYes ❑No <br /> Custody seals on shipping container? Intact ❑Broken ❑Not present VN/A <br /> Is COC Signed by Relinquisher? FzrYes ❑No Dated? 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? 9Yes EJ No <br /> Is COC free of whiteout and uninitialed cross-outs? ❑Yes E]No Whiteout gNo,Cross-outs <br /> Sample Inspection <br /> Coolant er Present: 3 Yes 'n No(includes water /l/7iv U.73 <br /> Temperature C Therm.ID# f� Initial Date/Tim6 ❑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? ❑YesNo <br /> Are any sample containers broken, leaking or damaged? E]Yes No <br /> Are preservatives indicated? pTyes,on sample containers ❑Yes,on COC FNot indicated ❑N/A <br /> Are preservatives correct for anal ses 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 E]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 De Is <br /> Matrixv� Container type___u #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: 1((7J6 Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) On Both E]Not indicated <br /> If Sample ID's are listed on both COC and containers, do they all match? es �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 NNo ❑N/A <br /> COMMENTS: I�JYI�� ( �_ O I� �'� t✓\ \)Q A S //1A0 <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 7 of 7 <br />