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KIFFO RECEIVER <br /> DA <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: 7 S:)5-- Date: 0 ZI/0 <br /> Project ID: <br /> Method of Receipt: Courier ver-the-counter iZ&thipper <br /> COC Inspection <br /> Is COC present? rue`s ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present f�tN/A <br /> Is COC Signed by Relinquisher? .Yes [:]No Dated? -R]Yes ❑No <br /> Is sampler name legibly indicated on COC? CKyes ❑No <br /> Is analysis or hold requested for all samples es ❑No <br /> Is the turnaround time indicated on COC? WYes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? Yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: q!$YesNo(includes water) <br /> Temperature'C Therm. ID#J ` Z Initially Date/Time /o z//y f 2Z Z- ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken (Efilot 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 2rNo <br /> Are any sample containers broken, leaking or damaged? ❑Yes LNo <br /> Are preservatives indicated? Yes,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 ❑No <br /> Receipt Details <br /> Matrix112,a Container typeA #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: / 0 2//0 Time:'L2Z S� <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) Z On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? Z Yes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) ©On Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? ["'es ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) Z]On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? [&'es ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) 4 On Both []Not indicated <br /> If collection times are listed on both COC and containers,do they all match? Yes ❑No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 24 of 31 Page 15 of 15 <br />