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KIFFO RECEIVER <br /> 79 <br /> Analvtical u-c SAMPLE RECEIPT CHECKLIST ' <br /> q Initials <br /> SRG#: �ff U Date: 0�Z o I <br /> Project ID: '30M AOA 34411 C71A_ (t6l Fy� <br /> Method of Receipt: Pkourier Over-the-counter Shipper <br /> COC Insaection <br /> Is COC present? KYes ❑No <br /> Custody seals on shipping container? ❑Intact [—]Broken ❑Not present RJN/A <br /> Is COC Signed by Relinquisher? E-Yes ❑No Dated? j Yes E]No <br /> Is sampler name legibly indicated on COC? Yes ❑No <br /> Is analysis or hold requested for all samples RYes E]No <br /> Is the turnaround time indicated on COC? Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? ❑Yes ❑No, Whiteout RNo, Cross-outs <br /> Sample Inspection <br /> Coolant Present: RYes 7 No(includes water) <br /> Temperature°C�f. Therm. ID# J —I Initial T.T6 Date/Time O 7ZU!(/ (�z E]N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken gNot present <br /> Do containers match COC? RYes ❑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 ENo <br /> Are preservatives indicated? ayes,on sample containers Yes,on COC []Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? Yes ❑No ❑N/A <br /> Are samples within holding time for analyses requested? Yes E]No <br /> Are the correct sample containers used for the analyses requested? Yes ❑No <br /> Is there sufficient sample to perform testing? lyes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes kNo <br /> Receipt Details <br /> Matrix WA Container type WA #of containers received 103 <br /> Matrix (NA Container type Ary,k,— #of containers received Z� <br /> Matrix_(" Container type Wal #of containers received i 1 <br /> Date and Time Sample Put into Temp Storage Date: ('_J'W I ( Time: i 6 S F` <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample ctnte' s) On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? esKNo E]N/A <br /> Is the Project ID indicated: E]On COC E]On sample container(sn Both E]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) W On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers, do they all match? k}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 an containers,do they all match? ❑Yes ❑No /J� --y- /A pp <br /> COMMENTS: t7 ��s / O 7 ;i/J� 0720) 1 <br /> - a7 S - Ld-C2- Q-7201 ' 1 OS <br /> ib -fix bw r s QC T3-- z COC- <br /> 1444 07 2.01 /(13 <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 113 of 113 <br />