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Recervea <br /> K1 FF H /�/ q <br /> AnaWtical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> iSRG#: (C(O 14- Date: Z30`( 1 <br /> Project ID: �f4 L-4- L�n Cd�in S'�YJ l/f OG�&A Jus art l.U9 �' ) <br /> Method of Receipt: Courier n Over-the-counter El Shipper <br /> COC Inspection <br /> i Is COC present? Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present 8 N/A <br /> Is COC Signed by Relinquisher? Yes ❑No Dated? P Yes ❑No <br /> Is sampler name legibly indicated on COC? ®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 oNo,Cross-outs <br /> i Sample Inspection <br /> Coolant Present: Yes <br /> No5includes water <br /> ne []N/ATemperatu °C Therm.ID# R- Initial Date/Tit � / <br /> Are there custody seals on sample containers? ❑Intact ❑Broken In Not present <br /> i Do containers match COC? �R Yes ❑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 ZNo <br /> Are any sample containers broken,leaking or damaged? E]Yes No <br /> i Are preservatives indicated? E]Yes,on sample containers ElE] ❑Yes,on COC E]Not indicatedN/A <br /> Are preservatives correct for analyses requested? Yes No N/A <br /> Are samples within holding time for analyses requested? Q Yes ❑No <br /> Are the correct sample containers used for the analyses requested? ®Yes ❑No <br /> i Is there sufficient sample to perform testing? Yes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes ®No <br /> Receipt Details <br /> Matrix_ Container type SI_c r #of containers received <br /> i Matrix Container'type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: CYO 2300( Time: <br /> i uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) On Both E]Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? C]Yes �No ❑N/A <br /> Is the Project ID indicated: C&On COC ❑On sample container(s) ❑On Both ❑Not indicated <br /> i 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: (1�0 COC ❑On sample containerE]s) On Bo ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? ❑Yes ❑No 9,N/A <br /> i Are the sample collection times indicated: i;a4pn COC ❑On sample container(s) ❑On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? ❑Yes ❑No ®.N/A <br /> COMMENTS: —/2- I "D GY, 5- - 6 S — <br /> ' aJ( eo czy- Z309 I n i <br /> 1 <br /> 1 <br /> 0:\o1d_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> i <br />