Laserfiche WebLink
KIFF0 RECEIVER <br /> Analvtical «C SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: �t'p Date: <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? 2rYes ❑No Dated? 'Eyes ❑No <br /> Is sampler name legibly indicated on COC? ❑Yes / No <br /> Is analysis or hold requested for all samples Yes ❑No <br /> Is the turnaround time indicated on COC? zyes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? Yes ❑No, Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: AYes No(includes water <br /> Temperature°C �•to Therm. ID# ��� Initial Date/Time 21010 1(a 4- ❑N/A <br /> Are there custody seals on sample containers? E]Intact ❑Broken Not present <br /> Do containers match COC? �Yes E]No [-]No,COC lists absent sample(s) E]No,Extra sample(s)present <br /> Are there samples matrices other than soil,water,air or carbon? ❑Yes ONO <br /> Are any sample containers broken,leaking or damaged? ❑Yeso <br /> Are preservatives indicated? OYes,on sample containers ❑Yes,on COC tj Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? Yes ❑No ❑N/A <br /> Are samples within holding time for analyses requested? ❑No <br /> Are the correct sample containers used for the analyses requested? res <br /> es ❑No <br /> Is there sufficient sample to perform testing? 9ryes ❑No <br /> Does any sample contain product,have strop odor or are otherwise suspected to be hot? ❑Yes P�No <br /> Receipt ils <br /> Matrix Container type_ #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container typei #of containers received <br /> d <br /> ,L� <br /> Date and Time Sample Put into Temp Storage Date: t D t,b Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) N�On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? Q Yes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) ,�90n Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? 4Yes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) A On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? g)Yes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) O <br /> n Both E]Not indicated <br /> If collection times are listed on both COC and containers,do they all match? �i'es ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 18 of 25 Page 10 of 10 <br />