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KIFF0 <br /> RECEIVER <br /> Analytical LLC SAMPLE RECEIPT CHECKLIST ,,`` InitiY <br /> SRG#: S777 3 Date: I ��V <br /> Project ID: <br /> Method of Receipt: ❑Courier 4 Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Yes ❑No <br /> Custody seals on shipping container? 9JIntact ❑Broken ❑Not present 71 N/A <br /> Is COC Signed by Relinquisher? [/Yes ❑No Dated? Yes ❑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? Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? ❑Yes ❑No,Whiteout Oo, Cross-outs <br /> Sample Inspection <br /> Coolant Present Yes No(includes water <br /> Temperature C Therm. � <br /> ID# z..- Initial a/Time�LS� , E]N/A <br /> Are there custody seals on sample containers? Intact ❑Broken Not present <br /> Do containers match COC? Z 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 RNo <br /> No <br /> Are any sample containers broken, leak' g or damaged? tes,ln <br /> � -- <br /> Are preservatives indicated? Yes, on sample containers COC ❑Not indicated ❑N/A <br /> Are reservatives correct for analy es requested? es ❑No ❑N/A <br /> P <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 suspected to be hot? ❑Yes �No <br /> Receipt et ils ��((�� L+ <br /> Matrix Container type .�cC�(A.(� #of containers received <br /> Matrix Container type � _6 #of containers received <br /> Matrix Container type #of containers received <br /> ora <br /> Date and Time Sample Put into Temp Stge Date. (�i(�( y Time: v"► <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? 4 Yes N No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) LJOn Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? F Xes L No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) K On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? C%Yes ❑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? XYes ]No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 22 of 22 <br />