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RECEIVER KIFFOTY6 Analvtical u.c SAMPLE RECEIPT CHECKLIST Initials t SRG#: 2 Ze-( 51f Date: Project ID: A\0�' f FeL .- Method of Receipt: I&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? [SYes ❑ No Custody seals on shipping container? ❑ Intact ❑ Broken [—]Not present nN/A is COC Signed by Relinquisher? ® Yes ❑ No Dated? K 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? $j Yes ❑ No Is COC free of whiteout and uninitialed cross -outs? O Yes ❑ No, Whiteout ❑ No, Cross -outs Sample Inspection Coolant Present: ®.Yes No (includes water Temperature °C % Therm. ID#t Initial Q% Date/Time ❑NIA Are there custody seals on sample containers? L]Intact ❑ Broken ®Not present Do containers match COC? Ryes ❑ 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? E] Yes No Are preservatives indicated? ❑ Yes, on sample containers Yes, on COC 5 ❑ Not indicated ❑ NIA Are preservatives correct for analyses requested? Yes ❑ No ❑ NIA Are samples within holding time for analyses requested? ® Yes ❑ No Are the correct sample containers used for the analyses requested? (E] 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 RNo Receipt Details Matrix_ -w1- Container type \10A# of containers received Matrix Container type # of containers received Matrix Container type # of containers received Date and Time Sample Put into Temp Storage Date: ^ 101412- Time: j ysZ uicklo Are the Sample ID's indicated: ❑ On COC ❑ On sample container(s) On Both ❑ Not indicated If Sample ID's are listed on both COC and containers, do they all match? [IR Yes ❑ No ❑ NIA Is the Project ID indicated: ❑ On COC ❑ On sample container(s) ® On Both ❑ Not indicated If project ID is listed on both COC and containers, do they all match? [5,Yes ❑ No ❑ NIA Are the sample collection dates indicated: O On COC ❑ On sample containers) Ron Both ❑ Not indicated If collection dates are listed on both COC and containers, do they all match? (Yes [] No ❑ NIA Are the sample collection times indicated: ❑ On COC ❑ On sample container(s)On Both EJNot indicated If collection times are listed on both COC and containers, do they all match? � Yes n ❑ N/A COMMENTS: 0Ao1d_edlsamprccVorms\Samplc Receipt Checklist rev 072412.doc Paqe 7 of 7