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Kl FF RECEIVER <br /> Analvtical «c SAMPLECEIInitials <br /> PT CHECKLIST nittials <br /> SRG#: � Z Date: tJ <br /> Project ID: f C,_'-ce ( � <br /> Method of Receipt: urier ❑Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Ryes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present EJJN/A <br /> Is COC Signed by Relinquisher? es ❑No Dated? [}�i'es ❑No <br /> Is sampler name legibly indicated on COC? [ Yes ❑No <br /> Is analysis or hold requested for all samples RYes ❑No <br /> Is the turnaround time indicated on COC? 5aYes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? ❑Yes ❑No,Whiteout _,Cross-outs <br /> Sample Inspection <br /> Coolant Present: Ryes ❑No includes wate <br /> Temperature°C - 0 Therm. ID# Initial Date/Time (9YI N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken ot present <br /> Do containers match COC? LaYes E]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 k�'No <br /> Are preservatives indicated? ❑Yes,on sample containers Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? Ryes ❑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? syes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? Yes [g N0 <br /> Receipt DetailsLA—A."e-1 <br /> !/ <br /> Matrix 4- Container type ,� #of containers receive l C� <br /> Matrix_L,44- Container type i�� #of containers received <br /> Matrix f-44 Container type ;L <br /> #of containers received <br /> Date and Time Sample Put into Temp Storage Date. C7�j i Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) '�90n Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? ' Yes [J No E]N/A <br /> Is the Project ID indicated: ❑On COC E]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 sam le container(s) ,A On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? P9--yes ONo ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) aOn Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? l7bYes hh❑No ❑N/A <br /> COMMENTS: �f ✓1') e on COC �U r U\ SSO)VtJ e`-ci S <br /> LA <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 180 of 180 <br />