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RECEIVER <br /> KIFFO <br /> -99 <br /> Analvtical LLc SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: -7 3 6 3 Date: Vnn 70 /�7 / O <br /> Project ID: e5 e_ <br /> Method of Receipt: Courier Over-the-counter Whipper <br /> COC Inspection <br /> Is COC present? es ❑No <br /> Custody seals on shipping container? tact ❑Broken ❑Not present ❑N/A <br /> Is COC Signed by Relinquisher? Oyes ❑No Dated? es ❑No <br /> Is sampler name legibly indicated on COC? Yes RWO <br /> Is analysis or hold requested for all samplesaes <br /> es No <br /> Is the turnaround time indicated on COC? ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? Wes ❑No,Whiteout [:]No,Cross-outs <br /> Sample Inspection / <br /> Coolant Present: 2 Wes n No includes water) a707t �/ l 7I 8 ❑N/A <br /> Temperature C Therm. ID#� Initial Date/Time <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Wot present <br /> Do containers match COC? 00yes ❑No ❑No,COC lists absent sample(s) No, Extra sample(s)present <br /> Are there samples matrices other than soil,water,air or carbon? E]Yes MNo <br /> Are any sample containers broken, le ingor damaged? ❑Yes ®No <br /> Are preservatives indicated? es,on sample containers ❑Yes,on COC [:]Not indicated ❑N/A <br /> Are preservatives correct for analys s requested? Yes ❑No ❑N/A <br /> Are samples within holding time for analyses requested? Yes ❑No <br /> Are the correct sample containers used for the analyses requested? Yes ❑No <br /> Is there sufficient sample to perform testing? WYes ❑No <br /> Does any sample contain product,have strong odor or are otherwise s*eected to be hot? ❑Yes Flo <br /> Receipt Details <br /> Matrix&A Container type VQA #of containers received I <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: 0-70710 Time: 17-3 0 <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) M On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers, do they all match? 45yes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) On Both E]Not indicated <br /> If project ID is listed on both COC and containers,do they all match? es f No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) ,H On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? , Yes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) ,ROn Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? �YYes ❑No ❑N/A <br /> COMMENTS: <br /> O:\old_edlsampreclForms\Sample Receipt Checklist rev 051409.doc <br /> Page 20 of 27 Pag@-1Nif/122A10 <br />