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1GFF0 RECEIVER <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST ]Wits <br /> SRG#: �'I 3M Date: ( 1S(O <br /> Project ID: Pi,rc est( !4 <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 ❑Broken ❑Not present/N/A <br /> is COC Signed by Relinquisher? eyes ❑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? zYes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? ❑Yes ❑No, Whiteout P?`No, Cross-outs <br /> Sample Inspection <br /> Coolant Present: YesNo(includes wate <br /> Temperature°C LZ_S Therm. ID# =Z Initial Date/Time 41ST 4H ❑N/A <br /> Are there custody seals on sample containers? Intact ❑Broken Not present <br /> Do containers match COC? ZYes ❑No ❑No, COC lists absent sample(s) ON <br /> o,Extra sample(s)present <br /> Are there samples matrices other than soil,water, air or carbon? ❑Yes o <br /> Are any sample containers broken, leaking or damaged? ❑Yes o <br /> Are preservatives indicated? ❑Yes,on sample containers ❑Yes,on COC ❑Not indicated /A <br /> Are preservatives correct for analyses requested? F]Yes ❑No N/A <br /> Are samples within holding time for analyses requested? Z 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 o <br /> Receipt'D`ails <br /> Y <br /> Matrix " Container type #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: ' ( ��C7 Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) 0 On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? es 0 No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) ZfOn 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) L�o On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? dgNes ❑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 ❑No ❑N/A <br /> COMMENTS: <br /> 01old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 7 of 7 <br />