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KIFFO RECEIVER <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST 2 1 Initials <br /> SRG#: 75795 Date: <br /> Project ID: 13 40 Kj Q 8 0 <br /> Method of Receipt: Courier ver-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Al Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not presentAN/A <br /> Is COC Signed by Relinquisher? Yes F]No Dated? Yes ❑No <br /> Is sampler name legibly indicated on COC? Yes EJ No <br /> Is analysis or hold requested for all samples Yes E]No <br /> Is the turnaround time indicated on COC? Yes E]No <br /> Is COC free of whiteout and uninitialed cross-outs? Yes ❑No, Whiteout E]No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: Yes uX No(includes water) <br /> Temperature°C Therm. ID# Initialer Date/Time Z!6/ 084 �� ❑N/A <br /> Are there custody seals on sample containers? '�R•Z ❑Intact ❑Broken NNot present <br /> Do containers match COC? Yes E]No E]No,COC lists absent sample(s) EJ No,Extra sample(s)present <br /> Are there samples matrices oth r than soil, water,air or carbon? ❑Yes �f No <br /> Are any sample containers broken, leaking or damaged? ❑Yes No <br /> Are preservatives indicated? E]Yes,on sample containers Yes,on COC Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? Yes E]No ❑N/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? Yes ❑No <br /> Does any sample contain product,have strong odor or are otherwise s spected to be hot? ❑Yes <br /> �Io <br /> Receipt Details <br /> MatrixVIA- Container type #of containers received <br /> Matrix�[a Container type #of containers received_ <br /> Matrix Container type of containers rece've <br /> Date and Time Sample Put into Temp Storage Date: 2 Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) P�Vn Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? es ❑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? Yes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) a On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? Owes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) ,@ On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? RYes ❑No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\$ample Receipt Checklist rev 051409.doc <br /> Page 8 of 8 <br />