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KIFF0 <br /> RECEIVER <br /> Analytical LLC SAMPLE RECEIPT CHECKLIST 1n"tials <br /> SRG#: �3 Date: I I D t 0 <br /> Project ID: T OA <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? 4,4-Yes ❑No <br /> Custody seals on shipping container? cE4btact ❑Broken ❑Not present ❑N/A <br /> Is COC Signed by Relinquisher? �'es ❑No Dated? •Yes E]No <br /> Is sampler name legibly indicated on COC? ❑Yes KN-0 <br /> Is analysis or hold requested for all samples <i'es ❑No <br /> Is the turnaround time indicated on COC? HlYes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? cff-y-es ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: 54-yes ElNo(includes water) <br /> Temperature°C 1. 6 Therm. ID# Initial Date/Time MO(C) 1350 ❑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 le(s) ❑No,Extra sample(s)present <br /> Are there samples matrices other than soil,water, air or carbon? ❑Yes 4�lo <br /> Are any sample containers broken, leaking or damaged? ❑Yes 'f�j Na <br /> Are preservatives indicated? yes,on sample containers ❑Yes, on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? JYes E]No ❑N/A <br /> Are samples within holding time for analyses requested? s [JNo <br /> Are the correct sample containers used for the analyses requested? s ❑No <br /> Is there sufficient sample to perform testing? s ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes 44<'No <br /> Receipt De ails <br /> Matrix VVA Container type vo #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 I t7 l[7 Time:J3!2 <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample conta'n (s) Z'On Both E]Not indicated <br /> If Sample ID's are listed on both COC and containers, do they all match? es ❑No E]N/A <br /> Is the Project ID indicated: E]On COC E]On sample container(s) ,�On Both ❑Not indicated <br /> If project ID is listed on both COC and containers, do they all match? Yes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC E]on sample container(s) On Both E]Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? �q Yes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) A On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? toYes ❑No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 24 of 38 Page 11 of 11 <br />