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Kl FF RECEIVER <br /> Analytical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: Date: 1 l 1 a([� <br /> Project ID: ki <br /> Method of Receipt: Courier Over-the-counter _Shipper <br /> COC Inspection <br /> Is COC present? ®`Y-es ❑No <br /> Custody seals on shipping container? ct ❑Broken ❑Not present ❑N/A <br /> Is COC Signed by Relinquisher? �es ❑No Dated? es ❑No <br /> Is sampler name legibly indicated on COC? Yes �No <br /> Is analysis or hold requested for all samples &S.Ye s ❑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: ayes ❑ o includes water) <br /> Temperature°C_Therm.ID# Initial— Date/Time !11610 /3 50 ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Not present <br /> Do containers match COC? QkXes ❑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 5�_o <br /> Are preservatives indicated? R1 Yes,on sample containers _Eiia4es,on OC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? /Ryes F-1No ❑N/A <br /> Are samples within holding time for analyses requested? &*—Nes ❑No <br /> Are the correct sample containers used for the analyses requested? KYes ❑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 QTIo <br /> Receipt Details `` <br /> MatrixLLk- Container type VOA #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: /11[)(0 Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? 4RV es �No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) CLJOn Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? c�3Yes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) c3'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) On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? CM Yes ❑No ❑N/A <br /> COMMENTS: <br /> OAold_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 19 of 21 Page 18 of 19 <br />