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KIFF RECEIVER <br /> L19YZI <br /> Analytical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: 7 55 O 2- Date: <br /> Project ID: IV e,5+-)-e. — yZ t 0✓1 <br /> Method of Receipt: Courier Over-the-counter 2;§hipper <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? Oyntact ❑Broken ❑Not present ❑N/A <br /> Is COC Signed by Relinquisher? WYes ❑No Dated? es E]No <br /> Is sampler name legibly indicated on OC? n YesFNo <br /> No <br /> Is analysis or hold requested for all samples es <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:25JYes E]No(includes water) /t l o 2 <br /> Temperature°C S, Therm. ID# , a- s Initial L-0--(ZDate/Time-11 `1 (I 3 ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Not present <br /> Do containers match COC? [o 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 ANo <br /> No <br /> E]Are any sample containers broken, leaking or damaged? Yes <br /> Are preservatives indicated? [FYes, 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 ,�J No <br /> Receipt Details V <br /> Matrix Container type 0 jz� #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 y) 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? JKJ Yes No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) 40n Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? E-Yes No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) On Both E]Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? nYes 9No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) Ro <br /> n Both E]Not indicated <br /> If collection times are listed on both COC and containers,do they all match? 0Yes ❑N/A <br /> COMMENTS: � Qin 0, -0-7- 6004 L of 4� <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 14 of 15 Page 13 of 13 <br />