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KIFFO <br /> O,Lc SAMPLE RECEIPT CHECKLIST Analvdcaluc <br /> _ SRG #: O"f O3q TAT: Standard Rush Split None <br /> Sample Receipt Initials/Date: 1 Storage Time: 3 Sample Login I Initials/Date: <br /> Method of Receipt: Courier D Over-the-counter ShiDped Shipping Custody Seals X N/A M Intact D Broken <br /> Tem `C i . WA Therm ID 3Q—I Time 1332 1 Coolant present KYes No D Water Temp Excursion <br /> Chain-of-Custody: Yes No Documented on COC Labels Discrepancies: <br /> Is COC resent? Sample ID Dz— )z� <br /> Is COC signed by relin uisher? x Project ID X <br /> Is COC dated by relin uisher? X Sample Date X-- <br /> Is <br /> LIs the sampler's name on the COC? Sample Time >L <br /> Are there analyses or hold for all samples? I Does COC match proiect history? N/A Yes No <br /> Samples: NIA Yes No Comments: <br /> Are sample custody seals intact? A <br /> Are sample containers intact? x <br /> Is preservation documented? X <br /> In-house Analysis: NIA Yes No <br /> Are preservatives acceptable? X <br /> Are sam les within holding time? X <br /> Are sample container types correct? loww <br /> Is there adequate sample volume? <br /> Receipt Details: <br /> Matrix Container Type #of Containers <br /> SD Je.2v� � <br /> CS Required: <br /> Proceed With Analysis: E] YES E] NO Init/Date: <br /> Client Communication: <br /> CDw <br /> 0 <br /> w <br /> 0:b10 edXsamprec Forms%Sample Receipt Checklist 05113 rmh <br />