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KIFF RECEIVER <br /> Analvticai u.c SAMPLE RECEIPT CHECKLIST Ins <br /> SRG#: Date: l PG G 0 <br /> Project ID: — <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? Intact ❑Broken ❑Not present ❑N/A <br /> Is COC Signed by Relinquisher? Yes F]No Dated? [ Yes ❑No <br /> Is sampler name legibly indicated on OC? ❑Yes No <br /> Is analysis or hold requested for all samples 4Yes ENo <br /> Is the turnaround time indicated on COC? 91Y <br /> es ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? es ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection l <br /> Coolant Present: Z/ Yes [–]No(includes wate 5 <br /> Temperature°C? `"Therm. ID# - `9–�; _ Initial Date/Time l W400 1 N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Not 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 ZJN o <br /> Are any sample containers broken, leaking or damaged? E]Yes No <br /> Are preservatives indicated? , Yes,on sample containers ❑Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? Yes ❑No E]N/A <br /> Are samples within holding time for analyses requested? ,❑'Yes ❑No <br /> Are the correct sample containers used for the analyses requested? ,QYes ❑No <br /> Is there sufficient sample to perform testing? ❑Yes '0'N0 <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes 7KN0 <br /> Receipt D is <br /> Matrix Container type #of containers received 2' <br /> Matrix Container type #of containers received <br /> Matrix Container type fi of containers received <br /> Date and Time Sample Put into Temp Storage Date: 11o Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) St'On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? ' 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? CT'Yes [ o ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) ff On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? tE�r_Yes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) J�&n Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? j5t!�Tes ❑No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 14 of 18 Page 13 of 13 <br />