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11UFF0 RECEIVER <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: t 3 Date: <br /> Project ID: O <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? CF��s ❑No <br /> Custody seals on shipping container? JKIntact ❑Broken ❑Not present ❑N/A <br /> Is COC Signed by Relinquisher? Yes ❑No Dated? es ❑No <br /> Is sampler name legibly indicated on COC? s ❑No <br /> Is analysis or hold requested for all samples 1AYes ❑No <br /> Is the turnaround time indicated on COC? t�$Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? Yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: F&Yes ❑No(includes water) <br /> Temperature°C Therm. ID# �g5 Initial Date/Time I ZJ410 O 15 [:]N/A <br /> Are there custody <br /> sa`ls-on sample containers? ❑Intact ❑Broken ot present <br /> Do containers match COC? `d� ❑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, P .No <br /> Are any sample containers broken,leaking or damaged? ❑Yes V�.No <br /> Are preservatives indicated? c?�Kes,on sample containers 40-yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? EYe's ❑No ❑N/A <br /> Are samples within holding time for analyses requested? s [:J No <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 (2F_b-4 <br /> Receipt Deta' s <br /> Matrix Container type #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:—��— I Q Time: 11 l am_ <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample conin r(s) 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?QYes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC El On sa ple container(s) On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? WYes ❑No ❑NIA <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) 0 On Both ❑Not indicated <br /> If collection times are listed on both COC and containers, do they all match? es U No ❑N/A <br /> COMMENTS: <br /> OAold_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doe <br /> Page 9 of 10 Page 8 of 8 <br />