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KIFF0 RECEIVER <br /> Analytical LLC SAMPLE RECEIPT CHECKLIST (,} lnitils <br /> SRG#: ^7,S 170 S Date: 1 I <br /> Project ID: /V elst l'e — 9 ), ()©1 <br /> I <br /> Method of Receipt: Courier ver-the-counter Shipper <br /> COC Inspection el <br /> Is COC present? VYes ❑No <br /> Custody seals on shipping container? Intact ❑Broken ❑Not present N/A <br /> Is COC Signed by Relinquisher? I?sKes ❑No Dated? Yes E]No <br /> Is sampler name legibly indicated o4 COC? Yes �]i No <br /> Is analysis or hold requested for all samples Yes ❑No <br /> Is the turnaround time indicated on COC? Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? Yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: OYes ❑No(includes water) <br /> Temperature°C Therm. ID# 'L Initial Date/Time Z i��/3� E]N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken JoNot 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 JZ No <br /> Are any sample containers broken,leaking or damaged? ❑YesNo <br /> Are preservatives indicated? 54 Yes,on sample containers ❑Yes,on COC NNot 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 )N�No <br /> Receipt Details <br /> Matrixes 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 ZZq ) D Time: L <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) EJOn Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? 2"Yes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) 2TOn Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? 7yes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container s) []'On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? ,❑YesNo ❑N/A <br /> Are the sample collection times indicated: E]On COC E]On sample contain (s) �On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? 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 12/30/2010 <br />