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®I Laboratories LLC <br />SAMPLE RECEIPT & REVIEW FORM <br />Client: I <br />^ PM (or PMA) review: Initials ON Date C PageN <br />____ of _ GL�CHL-SR-001 Rev 3 <br />Page 5 of 56 <br />50G/ARICOCWorkOrder: (J <br />Received B <br />Date Recelved: Qs d ,6 <br />Suspected Hazard Informationu <br />>' <br />o `If Net Counts > 100cpm on samples not marked "radioactive; contact the Radiation Saf Croufor further <br />Z p <br />iovcstigatioa. <br />COC/Samples marked as radioaclivr7— <br />Classified Radioactive rI or M b RSO? <br />Ma4mum Net Counts Observed' (Observed Counts - Area Background Counts): <br />COGSamples marked containing PCBs? <br />U yes, Wet'e swipes liken of sample containers <adion IevelsT <br />^ <br />Fackage, COC, and/or Samples marked as <br />beryllium or asbestos containing? <br />Shipped as a DOT Hazardous? <br />If Iti samples are to be ser aced as Safer Controlled Samples,and opened by the GM Safer Group. <br />Samples idenlifiod as Forei o Soil? <br />az�rd Class Shipped: UN# <br />Sample Recelpt Criteria <br />m <br />a• <br />< o <br />x 2 <br />CommenLs/Qualltiers (Required for Non -Conforming Items) <br />1 Shipping containers received intact and <br />Circle Applicable: Seals broken Damaged container Leaking container Other (describe) <br />scaled? <br />Preservation Method: Ice bags Blue ice Dry ice None Other (describe) <br />2 <br />Samples requiring cold preservation <br />within (0 < 6 dcg. C)?� <br />'Alltemperattues an recorded in Celan G <br />Tempanmre Device Serial a: <br />2a <br />Daily check performed and passed on IR <br />temperature gun? <br />Secondary Temperature Device Serial N Of Applicable): <br />3 <br />Chain of custody documents included <br />with shipment? <br />Circle Applicable: Seals broken Damaged eontrainer Leaking container Other (describe)4 <br />Sample containers intact and sealed? <br />5 <br />Samples requiring chemical preservation <br />Sample ID's, containers affected and observed pH: <br />at proper pH? —rpm <br />6 <br />Do Low Level Perchlorate samples have <br />Sample ift end-comainers'a.,=en: <br />headspace as requ(rFd? <br />7 <br />VOA vials contain acid preservation? <br />f unknown, ul«r No) <br />g <br />VOA vials free of headspace (defined as <br />Samplc ID's and containers affected: <br /><6uun bubble)? <br />9 <br />Are Encore containers present? <br />Yes. immediately deliver to volatiles laboratory) <br />1xilass- <br />10 <br />Samples received within holding tiule7 <br />19s and tests affected: <br />ll <br />Sample ID's on COC match ID's on <br />Sample ID's and containers affected:F LD <br />bottles? <br />12 <br />Date & time on COC match date & time <br />Sample lDt affected: <br />on bottles? <br />ENVIRONMENTAL HEALTH <br />13 <br />Number of containers received match <br />Sample ID's affected <br />IVIENT <br />number indicated on COC? <br />t ' <br />14 <br />Are sample containers identifiable as <br />CEL provided? <br />15 <br />COC form is properly signed in <br />relinquished/received sections? <br />G,de Applicable: <br />FedEx Air FedEx Ground UPS Field Services Courtier Other <br />16 Carrier and tracking number. <br />Comments (Use Continuation Form if Deeded): <br />^ PM (or PMA) review: Initials ON Date C PageN <br />____ of _ GL�CHL-SR-001 Rev 3 <br />Page 5 of 56 <br />