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KIFF0Analytical LCC <br />SRG#: <br />Project ID: <br />Method of <br />SAMPLE RECEIPT CHECKLIST <br />Date: <br />1 � 1 � /�ia:�; -�eriV►a a�r� S�irr-rD%rates �✓�t� <br />COC Inspection <br />Is COC present? <br />Custody seals on shipping container? <br />Is COC Signed by Relinquisher? [.Yes ❑ No <br />Is sampler name legibly indicated on COC? <br />Is analysis or hold requested for all samples <br />Is the turnaround time indicated on COC? <br />Is COC free of whiteout and uninitiated cross -outs? <br />Sample Inspection <br />Over-the-counter <br />RECEIVER <br />TJX <br />Initials <br />>qYes <br />❑ No <br />❑ Intact <br />❑ Broken ❑ Not present MN/A <br />Dated?�f Yes <br />❑ No <br />Yes <br />❑ No <br />❑ No <br />9Yes <br />Yes <br />❑ No <br />❑ Yes <br />;No, Whiteout J,No, Cross -outs <br />Coolant Present: Yes ❑ No (includes water r <br />Temperature °C - �o Therm. ID# �R — 5— Initial DatelTime d �Z j , T ❑ N/A <br />Are there custody seals on sample containers? ❑ Intact ❑ Broken KNot present <br />Do containers match COC? ZlYes ❑ 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 No <br />Are any sample containers broken, leaking or damaged? [—]Yes No <br />Are preservatives indicated? XlYes, on sample containers 2 Yes, on COC ❑ Not indicated ❑ N/A <br />Are preservatives correct for analyses requested? bd Yes ❑ No ❑ N/A <br />Are samples within holding time for analyses requested? OYes ❑ 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 4No <br />Receipt Det its pp <br />Matrix Container type �,'1 # of containers received_ j <br />Matrix Container type v►? # of containers received .3 G <br />Matrix Container type v # of containers receive, <br />Date and Time Sample Put into Temp Storage Da e: Dy? r /0 Time:ZO <br />uicklo <br />Are the Sample ID's indicated: ❑ On COC ❑ On sample container(s) tfR.On Both ❑ Not indicated <br />If Sample ID's are listed on both COC and containers, do they all match? (�[ 'es ❑ No ❑ N/A <br />Is the Project ID indicated: ❑ On COC ❑ On sample container(s)n Both ❑ Not indicated <br />If project ID is listed on both COC and containers, do they all match? fes No ❑ N/A <br />Are the sample collection dates indicated: ❑ On COC ❑ On sample container(s) CJ�TOn Both ❑ Not indicated <br />If collection dates are listed on both COC and containers, do they all match? & Ces ❑ No ❑ N/A <br />Are the sample collection times indicated: ❑ On COC ❑ On sample contatner(s)n Both E]Not indicated <br />If collection times are listed on both COC and containers, do they all match? 4.:2 -Yes No ❑ N/A <br />COMMENTS: <br />O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br />Page 149 of 149 <br />