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KIFFO RECEIVER <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: ?.5 -- S 6 Date: 102-110 <br /> Project ID: ///d-ec"le— <br /> Method of Receipt: Courier ver-the-counter i er <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present §;JW/A <br /> Is COC Signed by Relinquisher? CE�es ❑No Dated? ]Yes ❑No <br /> Is sampler name legibly indicated on COC? c_-:E�Yes ❑No <br /> Is analysis or hold requested for all sampleses E]No <br /> Is the turnaround time indicated on COC? Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? Yes E]No,Whiteout E]No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: Yes E]No(includes water) <br /> Temperature°C /- F Therm. ID# /2 — 2 Initial Date/Time /4 2110 /Z_?_ Z S E]N/A <br /> Are there custody seals on sample containers? E]intact ❑Broken JjJ Not present <br /> Do containers match COC? Wes ❑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 o <br /> Are any sample containers broken, leaking or damaged? ❑Yes o <br /> Are preservatives indicated? 42Yes,on sample containers ❑Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses 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? Yes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes `f�(No <br /> Receipt Details `�^^ <br /> Matrix�7__2 Container typey T n #of containers received 2 0 <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: / 2 j/ Time: ZZ <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) A On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? s F]No ❑N/A <br /> Is the Project ID indicated: E]On COC E]On sample container(s) �`No <br /> n Both E]Not indicated <br /> If project ID is listed on both COC and containers, do they all match? Yes ❑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? V5 Yes �No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? MYes N No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 14 of 15 Page 13 of 13 <br />