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UM 1 Laboratories : c. <br />SAMPLE RECEIPT & REVIEW FORM <br />Client: j / A <br />Received By: <br />­navt..vwvvorx Urder: <br />Date Received: <br />Suspected Hazard Information <br />it a *If Net Counts > I00cpm on samples lint marked "radioactive", contact the Radiation Safet <br />Z in esdgation. y Group for further <br />COC/Samples marked as radioactive? <br />CWsifedR.adioacUuve 11 or Ill by RS01 <br />M-Nditnum Net Counts Observed* (Observed Counts -Area Background Cowtts): <br />COC/Samples marked containing PC8x7 <br />Were swipes taken ofsample containers < action levels? <br />Package, COC, and/or Samples marked as <br />beryllium or asbestos containing? <br />Shipped as a DOT Hazardous? <br />y Alskimples are to be sogregated as Safety Controlled Samples, and opened by the GEL Safety Group. <br />Samples identified as Foreign Soil? <br />azard Class Shipped: UNti: <br /><z Conmlents/Qualifiers (Required for Non -Conforming Items) <br />Sample Receipt Criteria <br />I Shipping containers received intact <br />Circle Applicable: <br />and sealed? <br />Seals broken Damaged container Leaking container Other (describe) <br />Preservation Method: Ice be ue ice Dry ice None Othei (describe) <br />r �� <br />2 <br />Samples requiring cold preservation <br />within (0:5 6 deg. C)1* <br />*all tempera recorded in Celsius <br />Temperature Device Serial p: <br />Secondary Temperamrc Device <br />2a <br />Daily check performed and passed on <br />IR <br />temperature un? <br />g <br />etS iaf 8 ( Applicabe): <br />3 <br />Chain of custody documents included <br />with shipment? <br />Applicable: <br />Seals broken Damaged container Leaking container Other (describe) <br />Sample ID's, containers affected and observed pH: <br />4 <br />Sample containers intact and sealed?Circle <br />5 <br />Samples requiring chemical <br />preservation at proper pH7 <br />Do Low Level Perchlorate samples <br />e rvatio ded LoW - <br />Sample ID's and rnntaincrs affected: <br />6 <br />(EPA 6850) have heads ace as <br />t ", <br />required? <br />7 <br />VOA vials free of headspace (defined <br />Sample ID's and containers affected: <br />as < 6mm bubble)? <br />F E8 G g ,ZW7 <br />8 <br />Are Encore containers present? <br />yes, immediately deliver to Volatiles laboratory) <br />H `ALT <br />9 <br />Samples received within holding <br />ID's and tests affected: <br />time? <br />G cp_, {TMANT <br />Sample ID's and containers affected: <br />10 <br />Sample ID's on COC match ID's on <br />bottles? <br />11 <br />late & time on COC match date & <br />Sample ID's affected: <br />time on bottles? <br />12 <br />Number of containers received match <br />Sample ID's affected: <br />number indicated on COC? <br />13 <br />Are sample containers identifiable as <br />GEL provided? <br />14 <br />COC form is properly signed in <br />relinquished/received sections? <br />Circle Applicable: <br />Eed:Fx Air FedEx Ground UPS Field Services Colmer Other <br />15 <br />Carrier and tracking number. <br />Comments (Use Continuation Form if needed): <br />r � <br />rrvi for rtv[n.) review: initials.. j 1 J Date _J (> 1I Lt%� ► I _ Page of GL -CHL -SR -001 Rev 1 <br />i <br />Page 5 of 17 <br />A <br />