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l< FF� RECEIVER <br /> AnalvtiCal LLC SAMPLE RECEIPT CHECKLIST In;t;als <br /> SRG#: (9�1 Date: uzco)o <br /> Project ID: 1010 CWMS - STt C <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? Yes E]No <br /> Custody seals on shipping container? ]Intact ❑Broken ❑Not present [K N/A <br /> Is COC Signed by Relinquisher? Yes ❑No Dated? Yes E]No <br /> Is sampler name legibly indicated on COC? E Yes ❑No <br /> Is analysis or hold requested for all samples ®Yes ❑No <br /> Is the turnaround time indicated on COC? Z Yes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? 9Yes ❑No,Whiteout []No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: &C Yes ❑No(includes water) <br /> Temperature°C 4.0 Therm. ID# xP,— 5' Initial -rlt Date/Time Q 209(0 l Iq0(,,!5 ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken [RNot 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 allo <br /> Are preservatives indicated? ELYes,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? Yes ❑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 (7 No <br /> Receipt Details <br /> Matrix�� Container typeyo,� #of containers received 15_0 <br /> Matrix Container type #of containers received <br /> Matrix Container type ,#of containers received <br /> Date and Time Sample Put into Temp Storage Date: 02olo Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) ROn 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: ❑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? �'es LNo ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) 00n Both ❑Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? cEg-'Yes ❑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? Yes -R No ❑N/A <br /> COMMENTS: A/'/- b CSG PA��fid I( I Al 3 Vb A S i w <br /> <S'n-At -7/YY-Z — 2- Sa /L <br /> A _ -rt7 wG - 2,Bn A 6 228 IQ <br /> O:\old_ed\samprec\Forins\Sample Receipt Checklist rev 051409.doc <br /> Page 26 of 26 <br />