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KIFFO RECEIVER �0B Analvtica► u.c SAMPLE RECEIPT CHECKLIST Initials SRG#: Date: 101a l 2 Project ID: 2A Method of Receipt: ❑Courier ,Over-the-counter ❑Shipper Shipping Only: ❑FedEx* ❑OnTrac* ❑Greyhound ❑Other *Service level if not Priority or Sunrise(M-F): COC Inspection Is COC present? '9Yes ❑No Custody seals on shipping container? F-1Intact [:]Broken E]Not present JCKN/A ❑ Is COC Signed by Relinquisher? tRYes No Dated? Yes ❑No Is sampler name legibly indicated on COC? Yes ❑No Is analysis or hold requested for all samples? Yes ❑No Is the turnaround time indicated on COC? Yes ❑No Is COC free of whiteout and uninitialed cross-outs? Yes ❑No,Whiteout ❑No,Cross-outs Sample Inspection Coolant Present: ®Yes ❑No(includes water _ Temperature°C Therm. ID# :,-,e- _3 Initial Date/Time 10[611 ZZI 0 -1 ❑N/A Are there custody seals on sample containers? ❑Intact ❑Brok n K Not present Do containers match COC? [ Yes ❑No [:]No,COC lists absent sample(s) ❑No,Extra sample(s)present Are there samples matrices other than soil,water,air or carbon? ❑Yes No Are any sample containers broken,leaking or damaged? ❑Yesu`�gro-1 No Are preservatives indicated? 0 Yes,on sample containers -�'FEAOc Not indicated ❑N/A Are preservatives correct for analyses requested? ®Yes ❑No ❑N/A Are samples within holding time for analyses requested? ®Yes ❑No Are the correct sample containers used for the analyses requested? Z Yes ❑No Is there sufficient sample to perform testing? [ Yes ❑No Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes JjZ"No Receipt Details Matrix WA Container type Vo A #of containers received 3 $_ Matrix w A Container type #of containers received 2- Matrix Af MatrixAf Container type #of containers received I• Date and Time Sample Put into Temp Storage Date: 1016( 1-2- Time: 16, 10 uicklo Are the Sample ID's indicated: ❑On COC ❑On sample container(s) ;N On Both ❑Not indicated If Sample ID's are listed on both COC and containers,do they all match? ELYesROn No E]N/A EJ Is the Project ID indicated: On COC On sample container(s) Both ❑Not indicated If project ID is listed on both COC and containers,do they all match? E-Yes ❑No ❑N/A Are the sample collection dates indicated: ❑On COC ❑On sample container(s) On Both ❑Not indicated If collection dates are listed on both COC and containers,do they all match? Alves MNo ❑N/A Are the sample collection times indicated: ❑On COC ❑On sample container(s) On Both E]Not indicated If collection times are listed on both COC and containers,do they all match? [ Yes [�]No ❑N/A COMMENTS: O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 072412.doc Page 22 of 22