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KIFF0RECEIVER <br /> `J, <br /> Analvtical «c SAMPLE EIPT CHECKLIST Initials <br /> SRG#: g Date: glib <br /> f <br /> Project ID: 4. <br /> Method of Receipt: ourier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? O—Ves ❑No <br /> Custody seals on shipping container? Intact ❑Broken ❑Not present �I/A <br /> Is COC Signed by Relinquisher? �es ❑No Dated? Yes E]No <br /> Is sampler name legibly indicated on COC? ❑Yes ONO <br /> Is analysis or hold requested for all samples '2�'es ❑No <br /> Is the turnaround time indicated on COC? 'Yes No <br /> Is COC free of whiteout and uninitialed cross-outs? es ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: Yes No i Ludes water <br /> Temperature°C� ?_ Therm. ID# V Initial Date/Time(& ��❑N/A <br /> Are there custody seals on sample containers? Intact ❑Broken 'Not present <br /> Do containers match COC? 2 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 .4�1No <br /> Are any sample containers broken, lea 'ng or damaged? ❑Yes ,rNo <br /> Are preservatives indicated? Z Yes,on sample containersYes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? es ❑No ❑N/A <br /> Are samples within holding time for analyses requested? ,yYes ❑No <br /> Are the correct sample containers used for the analyses requested? 211'es ❑No <br /> Is there sufficient sample to perform testing? Ta es ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes "No <br /> Receipt Details 2 <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers receiv d <br /> Date and Time Sample Put into Temp Storage Date:�0 1�c Time:1 <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) f?$On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? Tf`Yes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) &0n Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? @9.Yes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) Aon 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) RWn Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? Mes ❑No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 15 of 16 Page 14 of 14 <br />