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KIFFORECEIVER <br /> Analytical cu 1411W SAMPLE RECEIPT CHECKLIST tZJ� <br /> SRG#: c G/O �4 ,Date: 0C7-5-6 /q \ <br /> Project ID: 54t/z. L,-2- L Ac,,-)4 � (1-4a / J-g S`kzN l�huSl <br /> ' Method of Receipt: ECourier Over-the-counter Shipper <br /> COC Inspection <br /> 1 Is COC present? &Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not presentC N/A <br /> Is COC Signed by Relinquisher? C�Yes ❑No Dated? 10 Yes ❑No <br /> Is sampler name legibly indicated on COC? es ❑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 ZNo,Cross-outs <br /> Sample Inspection <br /> Coolant Present: rIzyesNo(includes water <br /> Temperature°C 2_B Therm. ID# ��-s Initial `T`6 Date/rime OGZ Svc/ ❑/ N/A <br /> Are there custody seals on sample containers? EJIntact E]Broken ®Not present <br /> Do containers match COC? ®'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 &No <br /> Are any sample containers broken,leaking or damaged? ❑Yes No <br /> ' Are preservatives indicated? ❑Yes,on sample containers ❑Yes,on COC ❑Not indicatedN/A <br /> E]Are preservatives correct for analyses requested? Yes [INo N/A <br /> Are samples within holding time for analyses requested? M Yes ❑No <br /> Are the correct sample containers used for the analyses requested? ED Yes ❑No <br /> Is there sufficient sample to perform testing? es ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes ®No <br /> Receipt Details <br /> Matrix Sa Container type S #of containers received 2 3 <br /> Matrix Containeftype #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: OGZ GZ9 Time: 17-5q <br /> Ouicklo <br /> 7-5quicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) Lgon Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? ..Wes LJ 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? Rryes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) n Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? ,W'es No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) 00n Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? Yes No ❑N/A <br /> COMMENTS: <br /> ' O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br />