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KI FF :R�EIVER Anaivrical L(c SAMPLE RE IIPT CHECKLIST f Initia s SRG#: �7 '�' Date: Project ID: ZA Method of Receipt: ❑Courier VJ Over-the-counter ❑Shipper Shipping Only: ❑FedEx* ❑OnTrac* ❑Greyhound ❑Other *Service level if not Priority or Sunrise(M-F): COC Inspection Is,COC present? V1 Yes ❑No Custody seals on shipping container? ❑Intact [:]Broken ❑Not present WTN/A Is COC Signed by Relinquisher? ZfYes ❑No Dated? [ryes ❑No Is sampler name legibly indicated on COC? Z Yes ❑No Is analysis or hold requested for all samples? Yes ❑No Is the turnaround time indicated on COC? 19Yes ❑No Is COC free of whiteout and uninitialed cross-outs? ;Z Yes ❑No,Whiteout ❑No,Cross-outs Sample Inspection Coolant Present: UYes No(includes water) ff Lb'! Z 23v Temperature°C Q • Therm. ID# f—3 Initial ate/Time ❑N/A Are there custody seals on sample containers? Intact ❑Broken 2"Not present Do containers match COC? ZrYes ❑No ❑No,COC lists absent sample(s) ❑No,Extra sample(s)present Are there samples matrices other than soil,water,air or carbon? ❑Yes ONO Are any sample containers broken,lea Ing or damaged? ❑Yes_ ❑'filo Are preservatives indicated? KYes,on sample containers es, SOC E]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? Yes E]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 ,�No Receip D ils Matrix (W—Container type #of containers received Matrix U41 Container type S #of containers received�� Matrix Container type #of containers received Date an ime Sample Put into Temp Storage Date:T()g(?—, Time: _ uicklo Are the Sample ID's indicated: ❑On COC ❑On sample container(s) KNI, n Both F-1Notindicated If Sample ID's are listed on both COC and co tainers,do they all match? VYeso ❑N/A Is the Project ID indicated: On COC ❑On sample container(s) ❑On Both ❑Not indicated If project ID is listed on both COC and conta'giers,do they all match? ❑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? Yes No ❑N/A Are the sample collection times indicated: E]On COC E]On sample contal er(s) On Both ❑Not indicated If collection times are listed on both COC and containers,do they all match? CP Yes ❑No ❑N/A COMMENTS: r, O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 072412.doc Page 22 of 22