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CALIFORNIA DEPARTMENT OF TOXIC SUBSTANCES CONTROL <br /> Environmental Chemistry,Laboratory <br /> 700 Heinz Avenue,Suite#150,Berkeley,CA 94710 <br /> Phone:(510)540-3111 smoffQdtsc.ca.gov <br /> SAMPLE RECEIPT CHECKLIST <br /> Authorization Number: tis Fc 00'Fl Date Received: U12.411% <br /> ECL No.:*B(0021 9 600088 S Time Received: 12'•50 aml <br /> Sample.Checklist Criteria: Part Yes No <br /> 1. .Sample Analysis Request (SAR)received with the sample(s)? <br /> 2. Sample received with proper preservation and information? <br /> 3. Chain of Custody complete? Names printed? Signed and Dsted? <br /> 4. Sample(s)received in a cooler/ice chest with ice/blue ice? <br /> b. Temperature of sample within15 6 PC? Observed Temp:el.2 °C' <br /> 6. Confirm prioritization list of Test Methods with requester? <br /> Sample Checklist Criteria: Part H <br /> T Custo y seal present and intact? <br /> 8. Sample condition acceptable (intact and no damage)? <br /> 9. Container size as noted on SAR? f <br /> 10. Do the number of samples on SAR and the number of samples on <br /> ARF agree? Are the within 20% range? <br /> 11.Aqueous and liquid samples in 40 mL VOA vials and no head space? ki A <br /> 12.Is there sufficient sample amount/volume for all analyses? <br /> see SOP on Environmental Sample Receipt, Handling and CoC) <br /> 13..Do sample labels.agree with SAR? <br /> 14,Are sample labels legible? <br /> 15.Are samples received in proper containers? (see SOP on Environmental <br /> Sample Receipt, Handling and CoC) <br /> 16. If received by FedEx or UPS is Air bill/packing sip signed and dated? N/pt <br /> 17. If supplemental analysis is requested, is it specified in Section 12 of SAR? <br /> 18. Did the Requester initial& date Section 12 of SAR? V <br /> Non acceptable discrepancies mentioned above were communicated to Requestor/Transporter: <br /> In Person:_Date: By Phone:_Dater By Email:_Date: <br /> Comments: <br /> Name: f r(rwyb MaV{e Iva . Signature:`X� Date: 12-/') <br /> Supervisor's Approval (if any corrective action taken): Date: <br /> DCN: 07,0071,00—Revision 2-11/6/2018—Approved.by QMO Page 1 of 7 <br />