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KI FF H RECEIVER Analvdcal ILC SAMPLE CEIPT CHECKLIST o Jl 1 l Initials SRG#: Z Date: 0/ Project ID: Lt C ✓ QV C1 1 COC InspectionMethod of Receipt: 7 Courier Over-the-counter El Shipper L Is COC present? JXYes []No L Custody seals on shipping container? ❑Intact ❑Broken ❑Not presegt. /A Is COC Signed by Relinquisher? fOYes ❑No Dated? Yes ❑❑No Is sampler name legibly indicated on'COC? Yes ❑No L Is analysis or hold requested for all samples Yes No Is the turnaround time indicated on COC? Yes ❑No Is COC free of whiteout and uninitialed cross-outs? ❑Yes ❑No, Whiteout Wo,Cross-outs Sample Inspection Coolant Present: [Wes Noincludes water) Temperature°C - Therm.ID# - Initial Date/Time t�� 1 SSo E]N/A Are there custody seals on sample containers? ❑Intact ❑Broken 75 pot present Do containers match COC? PYes ❑No ❑No,COC lists absent sample(s) ❑No,Extra sample(s)present Are there samples matrices other than soil,water,air or carbon? ❑YesNo Are any sample containers broken,leaking or damaged? E]Yes No Are preservatives indicated? [:]Yes,on sample containers ElYes,on COC ❑Not indicated ER N/A Are preservatives correct for analyses requested? ❑Yes ❑No N/A L Are samples within holding time for analyses requested? Yes EJNo Are the correct sample containers used for the analyses requested? 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 -ONo L Receipt Details ''DD Matrix SO Container type #of containers received Matrix Container type #of containers received Matrix Container type ,3O#/_o!containers ontainT�ereceived Ss C7 '— Date and Time Sample Put into Temp Storage y uicklo Are the Sample ID's indicated: ❑On COC ❑On sample container(s) t:�bln Both ❑Not indicated 6- If Sample ID's are listed on both COC and containers,do they all match? ZYes ❑No ❑N/A Is the Project ID indicated: ❑On COC ❑On sample container(s) , Orr Both ❑Not indicated If project ID is listed on both COC and containers,do they all match? WYes ❑No ❑N/A L Are the sample collection dates indicated: ❑On COC ❑On sample container(s) ,� Both ❑Not indicated If collection dates are listed on both COC and containers,do they all match? P Yes ❑No E]N/A Are the sample collection times indicated: E]On COC El On sample containers) ❑On Both JE�Not indicated If collection times are listed on both COC and containers,do they all match? ❑Yes ❑No ON/A 6- COMMENTS: I. L., ` Wcld_ed\sampmcToms\Sample Receipt Checklist rev 051409.doc Page 33 of 33