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SAMPLE RECEIPT CHECKUST Section 1:General Info _ �� 701 Date Received: 2 �'�`-�' WON t 4 G C Client: R'" C U F�s`.' �'�ct t.F i l-%i ri Section 2:Shipping/Custody � Are custody seals present?❑Yes No Custody seals intact on arrival? Id N/A [3 Yes E3 No [3 On cooler/box ❑On samples ❑Courier ❑Walk-In C3 Field Sampling 05�hipping Info: F` o rf Section 3a:Condition/Packaging 0 Outside 0.0-6.0'C(0.0-10.0'C for microbiology)(PM notified) Date Opened 2/ry/t C By(initials) Type of ice used: p'Wet ❑Blue/Gel ❑None ❑Samples received on ice directly from the field;cooling process had begun.(if checked,skip temperatures) ❑Sample matrix doesn't require cooling(e.g.air,bulk PCB).(if checked,skip temperatures) If no cooler.Observed/Adjusted Temp('C): / Thermometer/IR Gun: rrL ' CF: t°' f Cooler Temp('C)#1:.+ N2:____J_N3: ...1—N4: _N5:____/_N6:_/_ Section 3b:Microbiology Samples ONo microbiology samples submitted(skip 3b) ❑ Within temp range 0.0-10.0'C or received on ice directly from field. ❑Adequate headspace for microbiology analysis. Section 3c:Air Samples No air samples submitted(skip 3c) ❑1ALCanisters E3 6L Canisters ❑Tedlar Bags ❑MCE Cassettes ❑SorbentTubes ❑Other Section 4:Containers/Labels/Samples YES NO N/A 1)Were custody papers present,filled properly,and legible? 2)Is the sampler's name present on the CoC? / 3)Were containers received in good condition(unbroken/unopened/uncompromised)? 4)Were the samples bagged?(required for microbiology samples;recommended for soil samples) i 5)Were all of,and only,the correct samples received? i 6)Are sample labels present,legible,and In agreement with the CoC? / 7)Does the container count match the CoC? B)Was sufficient sample volume/mass received for the analyses requested? 9)Were samples received In proper can for the analyses requested? / 10)Were samples received with>1/2 holding time remaining? / 11)Are samples properly preserved as Indicated by CoC/labels? 12)Unpreserved VOAs received-If necessary,was the hold time changed in UMS? / 13)Are VOA vials free from headspace/bubbles>6mm? Section 5:Explanations/Comments (x m comments are made,then no discrepancies wled.) Cl No additional discrepancies Date Logged 247&1t ' By(print) (sign) M� Date Labeled By(print) - (sign) FMhalpy AnAyFcal 1-0006,R"2:Form Version 16.3020625 5of8