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KI tFF O <br /> SAMPLE RECEIPT CHECKLIST SRG#: SZ <br /> Sample Receipt I Initials/Date: YA^ b-7311::5 Storage Time: Z`f' Sample Login Initials/Date: AA'1'5 Cr7 3113 <br /> TAT: ❑Standard ❑Rush Split ❑ None Method of Receipt: ❑ Courier Over-the-counter Shipped <br /> ,Temp °C N/A Therm ID Time Coolant present es F No Water Temp Excursion <br /> For Shipments Only: Cooler Receipt Initials/Date/Time: Custody Seals 0 N/A Intact Broken <br /> Chain-of-Custody: Yes No Documented on COC Labels Discrepancies: <br /> Is COC resent? Sample ID <br /> Is COC signed by relin uisher? Project ID <br /> Is COC dated by relin uisher? Sample Date X <br /> Is the sampler's name on the COC? Sample Time I X <br /> Are there analyses or hold for all samples? Does COC match project history? " Yes No <br /> Samples: NIA Yes No Comments: <br /> Are sample custody seals intact? <br /> Are sample containers intact? <br /> Is preservation documented? <br /> In-house Analysis: NIA Yes No <br /> Are preservatives acceptable? <br /> Are samples within holding time? <br /> Are sample container types correct? <br /> Is there adequate sample volume? <br /> Receipt Details: <br /> Matrix Container Type #of Containers <br /> wh 3 <br /> �},n,•.ixv CS Required: ❑ <br /> Proceed With Analysis: ❑ YES ❑ NO Init/Date: <br /> CD <br /> W VwClient Communication: <br /> N <br /> O <br /> W <br /> N <br /> O:lold edlsamprefformslSample Receipt Checklist rev 070113.doc <br />