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RECEIVER <br /> KI FF H <br /> Analvtical LLC S LE �CEIPT CHECKLIST Initials <br /> SRG#: q I I �— GDaate: Ob/ ✓� ` _I _ <br /> Project ID: t�lQ �,P t' — t n C OI Y1 ✓' / 'e ( W1°�� N S7�l/q�) �h <br /> ' Method of Receipt: ourier EJ Over-the-counter Shipper <br /> COC Inspection <br /> ' Is COC present? Mes ❑No <br /> Custody seals on shipping container? Intact ❑Broken []Not present /A <br /> Is COC Signed by Relinquisher? Wes E]No Dated? Yes ❑No <br /> Is sampler name legibly indicated on OC? es ❑No <br /> Is analysis or hold requested for all samples Yes [-]No <br /> Is the turnaround time indicated on COC? Yes E]No <br /> Is COC free of whiteout and uninitiated cross-outs? Yes ❑No,Whiteout No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: �1 Wes ❑No includes water) <br /> Temperature°C . 'I Therm.ID# /Z- Initial Date(fime 4�C3G01 10616 []N/A <br /> Are there custody seals on sampl ontainers? ❑Intact ❑Broken ;6ejgot present <br /> ' Do containers match COC? V r I es ❑No ❑No,COC lists absent sample(s) ❑No,Extra sample(s)present <br /> Are there samples matrices othr than soil,water,air or carbon? ❑Yes "®No <br /> Are any sample containers broken,leaking or damaged? tes <br /> es EJNo <br /> Are preservatives indicated? [:]Yes,on sample containers es,on COC [_]Not indicated E]N/A <br /> Are preservatives correct for analyses requested? es [:]No ❑N/A <br /> Are samples within holding time for analyses requested? ❑No <br /> Are the correct sample containers used for the analyses requested? Yes ❑No <br /> 1 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 � �y <br /> Matrix W/4 Container type 0 <br /> #of containers received <br /> Matrix \P }& Containef type #of containers received <br /> �O _ <br /> Matrix_ _ Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date:�1 Time: <br /> ' e kloa <br /> the <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) ,9&Both Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? Alqes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) �bn Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? es ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sa6lple conteme s) �n Both []Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? �es ❑No ❑N/A <br /> ' Are the sample collection times indicated: ❑On COC ❑On sample containe s) �n Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? Des ❑No ❑N/A <br /> COMMENTS: r 2 o m 5.51 n SO mg f S fl h Z <br /> ok- C C- 74t c I L' �- + Ca d o r� <br /> 4rQ I) FA 50 o� tete q <br /> o✓rl t-lwrJ r) ez< 00 1 <br /> ' O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> i <br />