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RECEIVER <br /> DIFF H <br /> Analvticaf ttc SAMPLE RECEIPT CHECKLIST �Z�� ma us <br /> SRG#: ��11 f Date: I� \ <br /> Project ID: < fu LeA — Lin Cy�� ( LJ TtSRIU4lr`^S) <br /> 1 Method of Receipt: J&Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present E N/A <br /> Is COC Signed by Relinquisher? ElYes ❑No Dated? [ Yes ❑No <br /> Is sampler tame legibly indicated on COC? ayes ❑No <br /> Is analysis or hold requested for all samples OYes ❑❑No <br /> Is the turnaround time indicated on COC? Yes No <br /> Is COC free of whiteout and uninitialed cross-outs? Wes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: 9J,Yes []No mcludeswater) (o�q I � <br /> Temperature°C?.L _Therm.ID# -I:f Initial N ate Time 0 ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken KNot present <br /> Do containers match COC? 4Z 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 12 No <br /> Are any sample containers broken,leaking or damaged? ❑Yes o <br /> Are preservatives indicated? ❑Yes,on sample containers ❑Yes,on COC ❑Not indicated /A <br /> Are preservatives correct for analyses requested? ❑Yes ❑No /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? Ryes ❑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 .�'Q�"`� #of containers received f <br /> Matrix Container'type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: 0603061-- Time:&V <br /> iuicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) 5gOn Both E]Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? 9yes ❑No ❑N/A <br /> is the Project ID indicated: �On COC El On sample container(s) On Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? ❑Yes ❑No JRN/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) ESLOn Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? 9-Yes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) 4q On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? Myes []No ❑N/A <br /> COMMENTS: <br /> 1 <br /> O:\old_ed\sarnprec\Forms\Sample Receipt Checklist rev 051409.doc <br />