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KIFF RECEIVER <br /> ewe <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: :I t /��'�/i� C�Date: Z_4�j c> <br /> t�( <br /> Project ID: ty �Y�5- <br /> Method of Receipt: 2tourier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? 'Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present L;�3Q/A <br /> Is COC Signed by Relinquisher? 12�les ❑No Dated? Yes ❑No <br /> Is sampler name legibly indicated on COC? Z'Ves ❑No <br /> Is analysis or hold requested for all samples 0'Yes ❑No <br /> Is the turnaround time indicated on COC? ,-Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? E-yes ❑No, Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: ZYes ❑No(includes water) <br /> Temperature°C LL& Therm. ID# -X�U_< Initial Date/Time 6/ C [:]N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken , Not present <br /> Do containers match COC? Wes ❑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 ,EINO <br /> Are any sample containers broken, leaking or damaged? ❑Yes -E]'Nlo <br /> Are preservatives indicated? ❑Yes,on sample containers 'Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? , 'Yes ❑No ❑N/A <br /> Are samples within holding time for analyses requested? 13-yes ❑No <br /> Are the correct sample containers used for the analyses requested? Oves ❑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 EjNo <br /> Receipt Details '� /p��.,� <br /> Matrix_ Container type VY, #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: i-_0 D Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container s) .E On Both ❑Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container ) �Vy <br /> Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? �Yes ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container �On Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? 2ryes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample containe ) Fal6n Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? Yes ❑No ❑N/A <br /> COMMENTS: Q�: �� ='d' C b'Au2 <br /> �A.I-v y n to � � a � �l� eles_,t, <br /> �0 � d20V 6o I170 <br /> VON <br /> t, i l uw <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 45 of 45 <br />