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KIFF(A� n <br /> AnaNtical uc SAMPLE RECEIPT CHECKLIST f In; <br /> SRG#: „IA qospDate: Q I7 I ' <br /> Project ID / <br /> : Cat r 6((yH )je�V <br /> Method of Receipt: Courier Ll Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? 9Yes ❑No <br /> Custody seals on shipping container? Intact ❑Broken ❑Not present ®N/A <br /> Is COC Signed by Relinquisher? ®Yes ❑No Dated? Yes ❑No <br /> Is sampler name legibly indicated on COC? 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? Yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: ELYes ❑No(includes water q <br /> Temperature°C q,Z erm. ID# r�= Initial VJ 6 Date/fime !ol q/3 /].� ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Not present <br /> Do containers match COC? ®Yes ❑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? El Yes No <br /> Are preservatives indicated? SYes,on sample containers rOYes,on COC []Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? rg Yes ❑No ❑N/A <br /> Are samples within holding time for analyses requested? gYes ❑No <br /> Are the correct sample containers used for the analyses requested? ®Yes <br /> Is there sufficient sample to perform testing? —2pt`es fT No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes 04 No <br /> Receipt Details p <br /> Matrix w A Container type V d A #of containers received O <br /> Matrix UA Container typed #of containers received <br /> Matrix JA Container type #of containers received <br /> Date and Time Sample Pm into Temp Storage Date:_l V 1 y 1) Time: 16&K:- <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) ❑On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? ❑Yes ❑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) ❑On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? ❑Yes ❑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? ❑Yes F]No ❑N/A / <br /> COMMENTS: 20-557,'-61-e- tits tT)Li�� �1iu7O'C —0-5 . TSB 1011( 1631 <br /> 0:1old_c& mpmc\pom Sampk Receipt Checklist rev 051409.doc <br /> Page 8 of 8 <br />