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KIFFO T--rRECEIVER <br /> Analvdcal LLC SAMPLE EIPT CHECKLISTn,I tials <br /> SRG#: Date: to <br /> Project ID: Part-� <br /> Method of Receipt: Courier XOver-the-counter Shipper <br /> COC Inspection <br /> Is COC present? 01Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present.K N/A <br /> Is COC Signed by Relinquisher? KYes ❑No Dated? Yes E]No <br /> Is sampler name legibly indicated on COC? I Yes ❑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 uninitiated cross-outs? ❑Yes ❑No,Whiteout RfNo,Cross-outs <br /> Sample Inspection <br /> Coolant Present: 14 Yes ❑No(includes water) <br /> Temperature°C S, Therm. ID# TInitialtT1 Date/Time /UC� 1Q/ry ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Br ko en ®Not present <br /> Do containers match COC? tK 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 jNo <br /> Are any sample containers broken, leaking or damaged? ❑Yes P5No <br /> Are preservatives indicated? ®Yes, on sample containers ®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? WYes ❑No <br /> Are the correct sample containers used for the analyses requested? N Yes ❑No <br /> Is there sufficient sample to perform testing? FLYes ❑No <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? ❑Yes &No <br /> Receipt Details <br /> Matrix Container type NO #of containers received <br /> Matrix Container type wr h Pr #of containers received <br /> Matrix Container type k� #of containers received <br /> Date and Time Sample Put into Temp Storage Date: /001 Time: <br /> uicklo <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? Uyens <br /> ❑ IO E]Both]' <br /> Is the Project ID indicated: E]On COC E]On sample container(s) Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? �'es ❑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? KYes No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? WYes No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 24 of 24 <br /> i <br />