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Kl FF RECD <br /> Anaivticai«c SAMPLE RECEIPT CHECKLIST <br /> Initials <br /> SRG#: 7? 3,/ 7� Date: 00003 <br /> Project ID: 3 Q 1 I /hhA DVl +o r;n cg gpi d Sq yw p l"1101 ve vf�-- <br /> Method of Receipt: ❑Courier ver-the-counter ❑Shippeir <br /> COC Inspection <br /> Is COC present? Mes ❑No <br /> Custody seals on shipping container? F❑Intact ❑Broken ❑Not present A N/A <br /> Is COC Signed by Relinquisher? D4Yes ❑No Dated? Yes ❑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 4 No,Cross-outs <br /> Sample Inspection <br /> Coolant Present I Yes i No(includes water �,I /� /�? ❑N/A <br /> Temperature C 0— Therm.ID# 7-- Initial Date/Time / b <br /> Are there custody seals on sample containers? ❑Intact ❑Broken PNot present <br /> Do containers match COC? Yes E]No ❑No,COC lists absent sample(s) EJ No,Extra sample(s)present <br /> Are there samples matrices othe than soil,water,air or carbon? ❑Yes [ANo <br /> [:]Are any sample containers broken, leaking or damaged? Yes PnNo <br /> Are preservatives indicated? ❑Yes,on sample containers r9l 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 ❑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 No <br /> Receip Deta s , f Q <br /> Matrix Container type v o r } #of containers received <br /> Matrix W Container type L 12 b y #of containers received_ <br /> Matrix Container type r l �L containers received 2 <br /> Date and Time Sample Put into Temp Storage Date: Time: <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 ❑No ❑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 [-]No EJN/A <br /> Are the sample collection dates indicated: ElOn COC E]On sanfple container(s) JN On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? Yes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample cont iner(s) No <br /> n Both E]Not indicated <br /> If collection times are listed on both COC and containers,do they all match? Yes ❑N/A <br /> COMMENTS: f Q� V 1 es j 0 cr'I V 04S - LiT�2 0 <br /> 0Ao1d_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 24 of 24 <br />