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KIFF0 RECEIVER <br /> Analytical I.>.c SAMPLE RECEIPT CHECKLIST Ts <br /> trtitials <br /> SRG#: �g3p Date: <br /> Project ID: IAA6V_ v&A S`.lvl 4S2_ — <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? ®Yes ❑No <br /> Custody seals on shipping container? Intact ❑Broken ❑Not present AN/A <br /> Is COC Signed by Relinquisher? �Z Yes ❑No Dated? iYes ❑No <br /> Is sampler name legibly indicated on COC? W Yes ❑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? (K Yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: ( Yes ❑No(includes water) <br /> Temperature°C 0,(0 Therm.ID# T-2-Z Initial _7�!r6 Date/Time �I� 1 S� ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Not present <br /> Do containers match COC? MYes ❑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? [J Yes,on sample containers ❑Yes,on COC [:]Not indicated X N/A <br /> Are preservatives correct for analyses requested? C]Yes [:]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? r9Yes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes No <br /> Receipt Details 3 <br /> Matrix__ Container type _5102A^#_ #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Dake: 1 WZ0 Time: 1�D <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample containers) On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? eyes nNo ❑N/A <br /> Is the Project ID indicated: [:]On COC ❑On sample container(s) n Both [JNot 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) On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? cB Yes LJ 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? �-Xes �No ❑N/A <br /> COMMENTS: <br /> 0:\old_ed\samprec\Forrns\Sample Receipt Checklist rev 051409.doc <br /> Page 10 of 10 <br />