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KIFF 0 RECEIVER <br /> Analvtical ucSAMPL RECEIPT CHECKLIST Initials <br /> SRG#: �� 33 Date: O'ZOS I CD <br /> Project ID: N,1 o QW? -- STr& <br /> Method of Recei t: MCourier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? .Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present RN/A <br /> Is COC Signed by Relinquisher? 9yes ❑No Dated? MYes ❑No <br /> Is sampler name legibly indicated on COC? Yes ❑No <br /> Is analysis or hold requested for all samples [3Yes ❑No <br /> Is the turnaround time indicated on COC? [N Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? &Yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: 9.Yes ❑No(includes water <br /> Temperature°C Therm. ID#� 5- Initial Date/Time OZ03JO Z)Sb Z ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken 1K 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? fes <br /> es o <br /> [5E]Are preservatives indicated? .Yes,on sample containers es, on COC Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? es F1 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 ❑No <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 /10—No <br /> Receipt Details <br /> Matrix `J A Container type V014 #of containers received <br /> Matrix_" Container type AY #of containers received_t_ <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: _OZ©3 to Time: I_510 <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) XOn Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? M Yes ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) On Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? RYes 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? XKYes No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) On Both ❑Not indicated <br /> If collection times are listed on both COC and containers, do they all match? KY- No ❑N/A <br /> COMMENTS: <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 9 of 9 <br />