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RECEIVER <br /> ►DIFF H <br /> AnalytiCal «C SAMPLE RECEIPT CHECKLIST mM <br /> SRG#: 2 / q Date: 0 120 9 Of <br /> Project ID: <br /> �a Le� L4' (*y CIn �i vt1( 2, <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> Cnr In.oeetlon R yes ❑NO <br /> Is COC present? tact ❑Broken ❑Not present /A <br /> Custody seals on shipping container? <br /> Is COC Signed by Relinquisher? 5zYes ❑No Dated? XYes ❑No <br /> is sampler name legibly indicated od000? Yes E]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 uninitiated cross-outs? Yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: Wyes ❑No(includes water <br /> Temperature*c �_Oerm.ID# LK 'f Initial DateRime BJortU It 610 N/A <br /> Are there custody seals on sample containers? E)Intact E)Brokenof present <br /> 1 Do containers match COC? Jp5Yes ❑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 iNo <br /> Are any sample containers broken,leaking or damaged? ❑Yes KNo <br /> Are preservatives indicated? 1 Yes,on sample containers ,on COC Not indicated ❑N/A <br /> ' Are preservatives correct for analyses requested? .Yes E3No ❑N/A <br /> '(& <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? t[Yes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes ;No <br /> Receipt Detail <br /> MatrixW Container type %)P #of containers received <br /> Matrix Container type 0 #of containers received= <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date:-23-10-801 Time: 1 <br /> Arek <br /> log <br /> Are the Sample[D's indicated: ❑On COC ❑On sample container(s) 2On Both E]Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? E2Yes No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample containers) ®On Both ❑Not indicated <br /> 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: QOn COC ❑On sample container(s) ❑On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? ❑Yes ❑No RN/A <br /> Are the sample collection times indicated: 5LOn 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 EQ N/A <br /> COMMENTS: ?(/O deck An dU A 4 J 4 AJo c r <br /> TSL, 09Uya9 JRto <br /> 0:1o1d od\s=PMc\Fortns\S=ple Receipt Checklist rev 051409.doe <br />