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1<1FF RECEIVER <br /> Analvtical t_Lc SAMPLE RECEIPT CHECKLIST 1nit <br /> SRG#: Date: <br /> Project ID: <br /> Method of Receipt: 2<Ourier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? 21es ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present 0'N/A <br /> Is COC Signed by Relinquisher? �es ❑No Dated? ❑"Yes ❑No <br /> Is sampler name legibly indicated on COC? ❑Yes R10 <br /> Is analysis or hold requested for all samples des ❑No <br /> Is the turnaround time indicated on COC? Piles ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? Yes ❑No, Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: r12 [�es N (includes wat ) /��—� (g E]N/A <br /> Temperature°C ( Therm. ID# _ Initial Date/Time <br /> Are there custody seals on sample containers? ❑Intact ❑Broken [?-IQot present <br /> Do containers match COC? ['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 e-xo <br /> Are any sample containers broken, leak' g or damaged? E]Yes [moo <br /> Are preservatives indicated? Yes, on sample containers L; Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? lyes ❑No ❑N/A <br /> Are samples within holding time for analyses requested? ❑des ❑No <br /> Are the correct sample containers used for the analyses requested? 2 'es ❑No <br /> Is there sufficient sample to perform testing? Ves ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes 4 ' o <br /> Receipt De ai <br /> Matrix r Container type__t4DK . #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container type #_ f containers rece7d,,,__ <br /> Date and Time Sample Put into Temp Storage Date: L�"u 6 Time: (( <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) On Both E]Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? Yes 15No L]N/A <br /> Is the Project ID indicated: F]On COC E]On sample container(s) On Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? Yes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) �On Both E]Not indicated <br /> R <br /> If collection dates are listed on both COC and containers,do they all match? yes o ❑N/A <br /> Are the sample collection times indicated: ❑On COC E]On sample contalner(s) On Both E]Not indicated <br /> If collection times are listed on both COC and containers, do they all match? _XYes No E]N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Eorms\Sample Receipt Checklist rev 051409.doc <br /> Page 11 of 13 Page 10 of 10 <br />