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KIFF0 RECEIVER <br /> Analvtical«c SAMPLE RECEIPT CHECKLIST <br /> SRG#: Date: 02.0310 <br /> Project ID: \Q\0 QMS 'STTL <br /> Method of Receipt: 2 Courier Over-the-counter Shipper <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? IYes ❑No Dated? Yes ❑No <br /> CO <br /> Is sampler name legibly indicated on C? i Yes ❑No <br /> Is analysis or hold requested for all samples UYes ❑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: Z Yes ❑No(includes water) <br /> Temperature°C S-0 Therm.ID# .77(Z— ,- Initial T.Jr6 Date/Time OZO W Z 15 —L ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken ER 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 other than soil,water,air or carbon? ❑Yes No <br /> Are any sample containers broken, leaking or damaged? ❑Yes RNo <br /> Are preservatives indicated? 4Yes,on sample containers tes <br /> es,on COC []Not indicated E]N/A <br /> Are preservatives correct for analyses requested? es ❑No ❑N/A <br /> Are samples within holding time for analyses requested? es ❑No <br /> Are the correct sample containers used for the analyses requested? es <br /> EJ <br /> Is there sufficient sample to perform testing? ❑No <br /> Does any sample contain product, have strong odor or are otherwise suspected to be hot? ❑Yes RNo <br /> Receipt Details <br /> Matrix W N Container type NVA #of containers received 1 <br /> Matrix Container type #of containers received 12- <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: p'20310 Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) X]On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? Yes No ❑N/A <br /> Is the Project ID indicated: E]On COC ❑On sample container(s) � E]On Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? D[�Yes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) On Both Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? 9KYes ME]No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) On Both E]Not indicated <br /> If collection times are listed on both COC and containers,do they all match? N_Yes MNo ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 13 of 13 <br />