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CALIFORNIA DEPARTMENC OF TOXIC SUBSTANCES CONTROL <br /> Environmental Chemistry Laboratory <br /> 700 Heinz Avenue,Suite#150, Berkeley,CA 94710 <br /> Phone:(110)540-3111 smoff@dtsc,ca gov <br /> SAM E REC'EIP'T CI ECKLIS'T <br /> Authorization Number: It�4 01071 Date Received: � Il 2,4 Ila <br /> ECLNo.;'8CQ4Eft9 9400885 Time Received 1''L'-"50 arms <br /> Sample Checklist Criteria: Part I Yes No <br /> 1. Sample Analysis Request(SAR)received with the sample(s)? <br /> 2, Sample received with proper preservation and information? Ve <br /> 3. Chain of Custody complete? Names printed? Signed and Dated? 7777 <br /> 4. Sample(s)received in a coolertice chest with ice/blue ice? <br /> 6. Temperature of sample within s 6°C? Observed Temp;q,,Z °C ✓ <br /> 6. Confirm prioritization list of Test Methods with requestor? <br /> Sample Checklist Criteria; Part II <br /> 7. Custody seal present and intact? <br /> S. Sample condition acceptable(intact and no damage)? 1/ <br /> 9. Container size as noted on SAR? v <br /> 10. Do the number of samples on SAR and&number of samples on <br /> ARF ree? Are they within 20%ran e? <br /> 11.Aqueous and liquid samples in 40 mL VOA vials and no head space? VA <br /> 12. Is there sufficient sample amount/volume for all analyses? <br /> see SOP on Environmental Sample Receipt,Handling and Co, <br /> 13. Do sample labels agree with SAIL? <br /> 14. Are sample labels legible? <br /> 16.Are samples received in proper containers?(see SOP on Environmental ^ <br /> Sample Receipt, Handling and Cc <br /> 16. If received by FedEx or UPS is Air bill/packing sip signed and dated? <br /> 17. If supplemental analysis is requested,is it specified in Section 12 of SAR? <br /> 1S. Did the Requestor initial&date Seotian 12 of SAE? <br /> Non-acceptable discrepancies mentioned above were communicated to Requestor/'l`ransporter, <br /> In Person:,_„..Date; lay Phone: Date: 13y Email;,,._Date: <br /> Comments: <br /> Name: .Irr'iauua Signature; Date: 1 �_1! <br /> Supervisor's Approval(if any corrective action taken); Date: <br /> DCN; 07,0071.0O_Revision 2_11/6/2018_Appfoved by QMO Page 1 of 1 <br /> Page 12 of 15 <br />