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KIFFO RECEIVER <br /> Analytical LLC SAMPLE RECEIPT CHECKLIST Inr tials <br /> SRG#: 7-,F:7 8-1 Date: &IeR 1,57 <br /> Project ID: Parcd, 2A <br /> Method of Receipt: ❑Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? ntact ❑Broken ❑Not present J<N/A <br /> Is COC Signed by Relinquisher? [lyes ❑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? Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? 2qYes ❑No, Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: Yes ❑No(includes water) <br /> Temperature°C— A2, Therm. ID# :Z4-1 Initial -71-1; Date/Time 0q1,5// A-7ZO ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken L'Not present <br /> Do containers match COC? 19Yes ❑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 iNo <br /> Are any sample containers broken, leaking or damaged? fYS e [gNo <br /> Are preservatives indicated? Yes, on sample containers , on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? es ❑No ❑N/A <br /> Are samples within holding time for analyses requested? es ❑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 A Container type VOA #of containers received 5? <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: (q J Time: 1-71c <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? P9.yes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) _[ROn 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)__4g�On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? 'Layes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) ,ElcOn Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? es ❑No ❑N/A <br /> COMMENTS: <br /> Wold_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 24 of 24 <br />