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KIFFO <br /> RECEIVER <br /> Anaivticai ucSA RECEIPT CHECKLIST ��( S ials <br /> SRG# : ate : S <br /> Project ID : 5bdaQ <br /> Method of Receipt: ❑ Courier 1Z Ovemhewcountef Shipper <br /> Shipping Only: ❑ FedEx * ❑ OnTrac * ❑ Greyhound ❑ Other * Service level if not Priority or Sunrise ( M fl : <br /> COC Inspection <br /> Is COC present? Yes ❑ No <br /> Custody seals on shipping container? ❑ Intact ❑ Broken ❑ Not present aN/A <br /> Is COC Signed by Relinquisher? VYes ❑ No Dated? Z Yes ❑ No <br /> Is sampler name legibly indicated on COC ? , Yes ❑ No <br /> Is analysis or hold requested for all samples? zYes ❑ 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 : ❑ Yes �lo (includes water) <br /> Temperature °C Therm . ID# Initial Date/Time �6N/A <br /> Are there custody seals on sample containers? ❑ Intact ❑ Broken Not present <br /> Do containers match COC? Yes ❑ No ❑ No, COC lists absent sample(s) No, Extra sample(s) present <br /> Are there samples matrices othr than soil, water, air or carbon? ❑ Yes No <br /> Are any sample containers broken , leaking or damaged? ❑ Yes No <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? 7yes ❑ No <br /> Are the correct sample containers used for the analyses requested? ayes ❑ No <br /> Is there sufficient sample to perform testing? V1 Yes ❑ No <br /> Does any sample contain product, have strong odor or are otherwise supetted to be hot? ❑ Yes ;2'No <br /> Receipt D tails <br /> Matrix Container type # of containers received <br /> Matrix Container type # of containers received <br /> Matrix Container typeof co tainers recei d <br /> Date and Time Sample Put into Temp Storage Date : 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? Q5.yes ❑ ❑ N/A <br /> Is the Project ID indicated : f`� COC ❑ On sample contai r n ❑ Not indicated <br /> If project ID is listed on both COC and containers, do they all match ? es ❑ No /A <br /> Are the sample collection dates indicated : E] On COC ❑ On sample container(s) �Qn Both ] NNot indicated <br /> If collection dates are listed on both COC and containers, do they all match? 1Yes ❑ No ❑ N/A <br /> Are the sample collection times indicated : ❑ On COC ❑ On sample container(s) JKOn Both ❑ Not indicated <br /> If collection times are listed on both COC and containers, do they all match? jJYes ❑ No ❑ N/A <br /> COMMENTS : <br /> OAold_eftamprecTormASample Receipt Checklist rev 072412. doc <br /> Page 5 of 5 <br />