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Kl FF RECEIVER <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: 7 S Date: <br /> Project ID: ::��5 2z el <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? Yes ❑No Dated? Lwyes ❑No <br /> Is sampler name legibly indicated on OC? 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: a S [ Yes ❑No(includes water) <br /> Temperature°C ✓ Therm. ID# - 1 Initial�� Date/Time g I I I ( / )SS 10 ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken ,N Not present <br /> Do containers match COC? Yes E]No ❑No,COC lists absent sample(s) ❑No, Extra sample(s)present <br /> Are there samples matrices oth r than soil,water, air or carbon? ❑YesNo <br /> Are any sample containers broken, leaking or damaged? E]Yes No <br /> Are preservatives indicated? Yes,on sample containers E]Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analys s 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 sus ected to be hot? ❑Yes WNo <br /> Receipt Details <br /> Matrix W/A Container type a h'�bet'- #of containers received 2-- <br /> Matrix*""� _ Container type VOA #of containers received- 1,I L <br /> Matrix /1 Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: 0 Time: JS 5 CL <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 DNo ❑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? es E]No E]N/A <br /> Are the sample collection dates indicated: E]On COC E]On sa ple container(s) �30n Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? goes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample contai er(s) ,®On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? %W Yes ❑No ❑N/A // <br /> COMMENTS: ri'I �I O.M i � I, to "► i r1 Sq Y, .S ��'1� 9 <br /> v-f i+ o n +1�' e C 0C- .r am e w e s ,-f- 'IS V i1 m s)ct /< -l- <br /> y S / - ff3 Z <br /> — O 2- ok2J . L� ©gel /L 37 <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 24 of 24 <br />