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IM I LaboratorieS SAMPLE RECEIPT & REVIEW FORM <br />Client: LL- N L SDG/AR/COC/Work Order: <br />Received By: Date Received: A U � 0 Q <br />Suspected Hazard Information <br />*If Net Counts > 100cpm on samples not marke "radioactive", contact the Radiation Safety Group for further <br />investigation. <br />COC/Samples marked as radioactive? <br />IMaximum Net Counts Observed* (Observed Counts - Area Background Counts): 20 P <br />Classified Radioactive Il or III by RSO? <br />If yes, Were swipes taken of sample contatiners < action levels? <br />COC/Samples marked containing PCBs? <br />Shipped as a DOT Hazardous? <br />Hazard Class Shipped: UN#: <br />Samples identified as Foreign Soil? <br />Sample Receipt Criteriaz <br />z <br />Comments/Qualifiers (Required for Non -Conforming Items) <br />Shipping containers received intact <br />Circle Applicable: <br />1 <br />? <br />and scaled? <br />7` <br />Seals broken Damaged container Leaking container Other (describe) <br />Samples requiring cold preservation <br />Preservation Method: Ice bags Blue ice Dry ice None Other (describe) <br />2 <br />within (0 < 6 deg. C)?* <br />*all temperatures are recorded in Celsius <br />Daily check performed and passed on <br />Temperature Device Serial #: <br />2a <br />IR temperature gun? <br />Secondary Temperature Device Serial # (If Applicable): / <br />l (o <br />3 <br />Chain of custody documents included <br />with shipment? <br />Circle Applicable: <br />4 <br />Sample containers intact and sealed? <br />Seals broken Damaged container Leaking container Other (describe) <br />Samples requiring chemical <br />Sample Ill's, containers affected and observed pH: <br />5 <br />preservation at proper pH? <br />VOA vials free of headspace <br />Sample ID's and containers affected: <br />6 <br />(defined as < 6mm bubble)'? <br />(If yes, immediately deliver to Volatiles laboratory) <br />7 <br />Are Encore containers present? <br />Samples received within holding <br />ID's and tests affected: <br />time? <br />Sample ID's on COC match ID's on <br />Sample ID's and containers affected: <br />9 <br />bottles? <br />ELL - <br />10 <br />Date & time on COC match date & <br />Sample ID's affected: <br />time on bottles? <br />Number of containers received match <br />Sample ID's affected: H <br />I1 <br />number indicated on COC? <br />DEPARTMENT <br />12 <br />Are sample containers identifiable as <br />GEL <br />�-s <br />provided? <br />13 <br />COC form is properly signed in <br />relinquished/received sections? <br />Circle Applicable: <br />•edEx Air FedEx Ground UPS Field Services Courier Other <br />14 <br />Carrier and tracking number. <br />^ 1= 2—o 4 09 <br />�E S <br />Comments (Use Continuation Form if needed): <br />PM (or PMA) review: Initials C • CAL, Date al -4007- Page I of <br />Page 5 of 39 <br />