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KI FF O <br /> uc SAMPLE RECEIPT CHECKLIST SRG#:cL <br /> Sample Receipt Initials/Date: �? jlt 7 7Storage Time: ( ?OD I Sample Login Initials/Date: OiL l( <br /> TAT: S andard ❑ Rush ❑ SPlit ❑ None Method of Receipt: ❑ Courier Over-the-counter ❑ Shipped <br /> n(, p D <br /> Temp °C N/A Therm ID A.3 Time (p Coolant present Yes No Water Temp Excursion <br /> For Shipments Only: Cooler Receipt Initials/Date/Time: Custody Seals ❑ N/A Intact Broken <br /> Chain-of-Custody: Yes No Documented on COC Lab s Discrepancies: <br /> Is COC resent? Sample ID <br /> Is COC signed by relin uisher? Project ID <br /> Is COC dated by relin uisher? Sample Date <br /> Is the sampler's name on the COC? Sample Time <br /> Are there analyses or hold for all samples? Does COC match project history? N/A XYes No <br /> Samples: N/A Yes No Comments: <br /> Are sample custody seals intact? <br /> Are sample containers intact? <br /> Is preservation documented? <br /> In-house Analysis: N/A Yes No <br /> Are preservatives acceptable? <br /> Are samples within holding time? <br /> Are sample container types correct? <br /> Is there adequate sample volume? <br /> Receipt Details: <br /> Matrix Container Type # of Containers <br /> (Z�5%),(/A Z <br /> CS Required: ❑ <br /> Proceed With Analysis: ❑ YES ❑ NO Init/Date: <br /> Client Communication: <br /> 0.kold edlsampreclFormslSample Receipt Checklist rev 070113.doc <br />