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I(IFF0A <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Q Initials <br /> SRG#: 1I ?� 5 Date: (}2C7a D <br /> Project ID: 0,10 CAMS STTC <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? E[Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present k /A <br /> Is COC Signed by Relinquisher? 0-Yes ❑No Dated? 6Q Yes ❑No <br /> Is sampler name legibly indicated on COC? tes <br /> es ❑No <br /> Is analysis or hold requested for all samples es E]No <br /> Is the turnaround time indicated on COC? ❑No <br /> Is COC free of whiteout and uninitiated cross-outs? Yes ❑No, Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: [&Yes ❑No(includes water) <br /> Temperature°C ,(' Therm. ID# -11Z— S Initial TIM Date/Time G ❑NIA <br /> Are there custody seals on sample containers? ❑Intact ❑Broken Not present <br /> Do containers match COC? 25-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? Yes,on sample containers W Yes,on COC ❑Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? R 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 XNo <br /> Receipt Deta is n <br /> Matrix l J Container type o 1 #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: Q W12 id Time: <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample ontamer(s) r>�oth E]Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match?L7 ( o ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample containers) n Both ❑Not indicated <br /> If project ID is listed on both COC and containers,do they all match? Eames ❑No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample nt ' 0 On Both E]Not indicated <br /> If collection dates are listed on both COC and containers,do they all match es No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) tlH`On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? �-es ❑No ❑N/A <br /> COMMENTS: <br /> T ih lte 61 WA (2-3-1v / <br /> Z-/ 02d&a <br /> �/99 3- /LI S /e A w-n, Y� Vot -- 0 re s `0C Vtf2' ; aA—er i-erW <br /> M -3 <br /> n WSro. <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 30 of 30 <br />