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1<1FF0 RECEIVER <br /> AnaNticai LLC SAMPLECEIPT CHECKLIST Initials <br /> SRG#: y�`� / Date: ©� f o /a <br /> Project ID: ZV'p�J�l Cp <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? CK Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present fN�N/A <br /> Is COC Signed by Relinquisher? VP Kyes ❑No Dated? fRYes ❑No <br /> Is sampler name legibly indicated on COC? Yes ❑No <br /> Is analysis or hold requested for all samples Yes ❑No <br /> Is the turnaround.time indicated on COC? Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? Yes ❑No, Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: C�YesNo(includes water) <br /> Temperature°C 2• M Therm. ID# I —2 Initial Q Date/Time �� ��/S ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken t�Not present <br /> Do containers match COC? C15-Yes ❑No ❑No,COC lists absent sample(s) ❑No,Extra sample(s)present <br /> Are there samples matrices other than soil,water,air or carbon? ❑Yes L3NO <br /> Are any sample containers broken,leaking or damaged? ❑Yes No <br /> Are preservatives indicated? des,on sample containers fes <br /> es,on COC Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? es E]No ❑N/A <br /> Are samples within holding time for analyses requested? es E]No <br /> Are the correct sample containers used for the analyses requested? es ❑No <br /> Is there sufficient sample to perform testing? ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes C 1Ao <br /> Receipt Details t �- <br /> Matrix ' 10 Container type V d #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date.a f Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) N On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? q�es ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) v;�170n Both ❑Not indicated <br /> If project ID is listed on both COC and containers, do they all match?C�'es ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? El<es ❑ o ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) t&On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? C7N es EJ No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 10 of 11 Page 9 of 9 <br />