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KIFFO RECEIVER <br /> Analytical «c SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: `7 g-0 Date: 072-111 <br /> �, <br /> Project ID: Q 1 1 f v'AOn� '�O rl ncj a Y1 J SPcl rhP 1 y �-k4_ <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? )H4wes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present gN/A <br /> Is COC Signed by Relinquisher? es E]No Dated? Yes ❑No / <br /> Is sampler name legibly indicated on OC? IvYes ❑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 Presentture'C I,i Yes No(includes <br /> it water_) „ O-72_i`� / 1 /5-5 ❑ <br /> Temperature C Therm.ID# Tom_ Initiate(,.,`-��DatelTime I p N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken of present <br /> Do containers match COC? Yes ❑No ❑No,COC lists absent sample(s) ❑No, Extra sample(s)present <br /> Are there samples matrices othl6r than soil,water, air or carbon? ❑YesNo <br /> Are any sample containers broken,leaking or damaged? ❑Yes No <br /> Are preservatives indicated? F-1Yes,on sample containers Yes,on COC RNot indicated ❑N/A <br /> Are preservatives correct for analyses 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 su pected to be hot? ❑Yes /D�PNo <br /> Receipt eta s <br /> Matrix Container type �Q #of containers received 22— <br /> Matrix Container type (� #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: 0 7 21 1 I Time: 71 O <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) �n Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? V Yes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s)A On Both F]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 sathple container(s) )a On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? es ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample cont iner(s)/J!§On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? Ppyes ❑No ❑N/A <br /> COMMENTS: SQVLt �� <br /> Com. o 72-/ // - 175 7 <br /> O:\old_ed\samprecTorms\Sample Receipt Checklist rev 051409.doc <br /> Page 108 of 108 <br />