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KIFFO RECEIVER <br /> Wb <br /> Analvticai LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: L.:& i Date: <br /> Project ID: Tesoro c6 C -rJhN n cw � <br /> Method of Receipt: Xcourier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? �s ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present$;�fN/A <br /> Is COC Signed by Relinquisher? 'Yes .❑No Dated? ❑Yes ,Mo <br /> Is sampler name legibly indicated on COC? .�'es ❑No <br /> Is analysis or hold requested for all samples es ❑No <br /> Is the turnaround time indicated on COC? *— es ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? es ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: esNo(includes waterr <br /> Temperature'C��Therm. ID#� —5'— Initial 1�7Date/Time 4)l Z� t r �' b�— ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken JS;,�,iot present <br /> Do containers match COC? es ❑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 o <br /> Are any sample containers broken, leaking or damaged? ❑Yes !Y ( o <br /> Are preservatives indicated? ❑Yes, on sample containers N t indicated /A <br /> Are preservatives correct for analyses requested? ,. Yes ❑No /A <br /> Are samples within holding time for analyses requested? Wyes ❑No <br /> Are the correct sample containers used for the analyses requested? ,Ryes ❑No <br /> Is there sufficient sample to perform testing? ->KJ Yes ❑No - <br /> Does any sample contain product,have strong odor or are otherwise suspected to be hot? F1 Yes No <br /> Receipt Details PP S`i /� <br /> Matrix 0 Container type ''oto'�— #of containers received <br /> Matrix Container type #of containers received <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: p 2 z-\ Q Time: 1 (� <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) �6n 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) CJft Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? Yes 'E]No E]N/A <br /> Are the sample collection dates indicated: E]On COC E]On sa ple container(s) n Both E]Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? �s No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) _L�[On Both ❑Not indicated <br /> If collection times are listed on both COC and containers, do they all match? ''Yes ❑No ❑N/A <br /> COMMENTS: v>t Is v ' C ✓u^^� <br /> ��tZZty <br /> i x"36 <br /> Wold_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 18 of 18 <br />