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K►FF RECEIVER <br /> L--j7-z-- <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Z q Initials <br /> SRG#: 7 511/10 Date: ' ! 1 <br /> Project ID: P Q 1 � O <br /> 1 <br /> Method of Receipt: Courier ver-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? ❑Intact []Broken ❑Not present PO/A <br /> Is COC Signed by Relinquisher? oftes ❑No Dated? Yes [—]No <br /> Is sampler name legibly indicated on OC? FYes WNo <br /> Is analysis or hold requested for all sampleses ❑No <br /> Is the turnaround time indicated on COC? %Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? 5211es ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: } P9 Yes No includes water) <br /> Temperature°C - I Therm. ID# Z InitiaDate/Time 2i2 q 10/13!� /�j <br /> ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Not present <br /> Do containers match COC? Yes ❑No E]No,COC lists absent sample(s) [:]No,Extra sample(s)present <br /> Are there samples matrices othet than soil,water,air or carbon? ❑Yes 2g No <br /> Are any sample containers broken,leaking or damaged? ❑YesNo <br /> Are preservatives indicated? Ryes,on sample containers E]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 sus ected to be hot? ❑Yes o <br /> Receipt etails /� <br /> Matrix Container type VQA- #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container type rr #of containers received <br /> Date and Time Sample Put into Temp Storage Date: l Z2�] Time: (3s <br /> Quickloll <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) -'On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? Poes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) �00n 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 ❑On sample contai er(s) �On Both E]Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? I Yes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) ,[S?On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? )4 Yes ❑No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 8 of 8 <br /> Page 9 of 12 01/07/2011 <br />