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1534 Willow Pass Road,Pittsburg,CA 94565-1701 <br /> MCCampbell Analytical, Inc. Toll Free Telephone:(877)252-9262/Fax:(925)252-9269 <br /> 4W "When Quality Counts" http://www.mccainpbell.com/E-mail:main@mccampbell.com <br /> Sample Receipt Checklist <br /> Client Name: Stockton Rubber Mfg.Co.,Inc. Date and Time Received: 7/2/2012 11:12:00 AM <br /> Project Name: #11075AN003;Pre-polymer Residue Determination Login Reviewed by: Maria Venegas <br /> WorkOrder N°: 1207007 Matrix: Solid Carrier: UPS <br /> Chain of Custody(CDC)Information <br /> Chain of custody present? Yes No❑ <br /> Chain of custody signed when relinquished and received? Yes No❑ <br /> Chain of custody agrees with sample labels? Yes 0 No❑ <br /> Sample IDs noted by Client on COC? Yes No❑ <br /> Date and Time of collection noted by Client on COC? Yes 0 No❑ <br /> Sampler's name noted on COC? Yes No❑ <br /> Samole Receipt Information <br /> Custody seals intact on shipping container/cooler? Yes ❑ No❑ NA <br /> Shipping container/cooler in good condition? Yes 0 No❑ <br /> Samples in proper containers/bottles? Yes No❑ <br /> Sample containers intact? Yes 0 No❑ <br /> Sufficient sample volume for indicated test? Yes 0 No❑ <br /> Sample Preservation and Hold Time(HT)Information <br /> All samples received within holding time? Yes W No❑ <br /> Container/Temp Blank temperature Cooler Temp: NA <br /> Water-VOA vials have zero headspace/no bubbles? Yes ❑ No❑ No VOA vials submitted 0 <br /> Sample labels checked for correct preservation? Yes 0 No❑ <br /> Metal-pH acceptable upon receipt(pH<2)? Yes ❑ No❑ NA❑�/ <br /> Samples Received on Ice? Yes ❑ No❑�/ <br /> NOTE:If the"No"box is checked,see comments below. <br /> Comments: <br /> Page 4 of 5 <br />