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r` p r/,} COOLER RECEIPT FORM 1) Project: �1/�/�7V ��1af Gr'r/147`�Zeoz Date Received: ? 2)Coolers: Number of Coolers: 3) '0 NO Were coolers and samples screened for radioactivity? 4) YES (TO Were custody seals on outside of cooler? How many? Date on seal? 5) Name on seal? 6) YES NO A Were custody seals unbroken and intact at the time of arrival? ��L C 7) YES NO Did the cooler come with a shipping slip(air bili, etc.)?Carrier name;_ _ ourrr 8) Shipping slip numbers:1) 2) 3) 9) YES NO Imo- Was the shipping slip scanned into the database? 10)YES 00 NA if cooler belongs to APPL, has it been logged into the ice chestatabase? 11) Describe type of packing in cooler (bubble wrap, popcorn, type of ice,etc.): L/Y' f 12) YES NO LCA For hand delivered samples was sufficient ice present to start the cooling process? 13)YDS NO Was a temperature blank included in the cooler? 14) Serial number of ce ified NIST thermometer used: Correction factor: 15) Cooler temp(s): 1) �, (2)_3)_4)_5) _6)_7)_8) Chain of custody: 16)*ENO Was a chain of custody received? 17)YDS NO Were the custody papers signed in the appropriate places? 18) YES NO Was the project identifiable from custody papers? 19) 'IffS NO Did the chain of custody include date and time of sampling? 20) lf>`S NO Is location where sample was taken listed on the chain of custody? Sample Labels: 21} S NO Were container labels in good condition? 22}YE9 NO Was the client 1D on the label? 23) Y58 NO Was the date of sampling on the label? 24) )(f€S NO Was the time of sampling on the label? 25) YES NO Did all container labels agree with custody papers? Sample Containers: 26) E9 NO Were all containers sealed in separate bags? 27} NO Did all containers arrive unbroken? 28) YES KO Was there any leakage from samples? 29) YES 1`46 Were any of the lids cracked or broken? 30) )T8 NO Were correct containers used for the tests indicated? 31)Yl�—S NO Was a sufficient amount of sample sent for tests indicated? 32) YES NO t�A Were bubbles present in volatile samples? It yes,the following were received with air bubbles: Larger than a pea: Smaller than a pea: Preservation & Hold time: 33))TS NO NA Was a sufficient amount of holding time remaining to analyze the samples? 34)YES NO P Do the sample containers contain the same preservative as what is stated on the COC? 35)YES NO 6A Was the pH taken of all non-VOA preserved samples and written on the sample container? 36) YES NO tfA Was the pH of acid preserved non-VOA samples<2 &sodium hydroxide preserved samples> 12? 37) YES NO P Unpreserved VOA Vials received? 38) YES NO l_QA Are unpreserved VOA vials noted in the ADD TEST FIELD on the ARF? Lab notified if pH was not adequate: Deficiencies: Signature of personnel receiving samples: Second reviewer: Signature of project manager notified: Date and Time of notification: Name of client notified: Date and Time of notification: Information given to client: by whom (Initials): FAFor)ns\1Vurkcheei-CooferRereipvdoc Revision 18,Augu.sr 2Q,2011