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Kl FF RECEIVER <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: -7-( ect q- Date: ()7 pg j O <br /> Project ID: 1&0 QAA5 511& <br /> Method of Receipt: Courier El Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? yes ❑No <br /> Custody seals on shipping container? ❑intact ❑Broken ❑Not present Q]N/A <br /> Is COC Signed by Relinquisher? tC Yes ❑No Dated? Yes ❑No <br /> Is sampler name legibly indicated on COC? Yes ❑No <br /> Is analysis or hold requested for all samples ®Yes ❑No <br /> Is the turnaround time indicated on COC? ElYes ❑No <br /> Is COC free of whiteout and uninitialed cross-outs? Q Yes ❑No,Whiteout ❑No,Cross-outs <br /> Sample Inspection <br /> Coolant Present: /L -Yes ❑No(includes water) <br /> moi <br /> Temperature°C ,0 Therm. ID# -Z2— 5' Initial T�T6 Date/Time 07,0810 l ao& ❑N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken ®Not present <br /> Do containers match COC? KYes ❑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 ANo <br /> Are preservatives indicated? ®-Yes,on sample containers ®Yes,on COC ❑Not indicated ❑NIA <br /> Are preservatives correct for analyses requested? N 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 gNo <br /> Receipt Details <br /> Matrix Container type #of containers received f <br /> Matrix Container type #of containers received <br /> Matrix Container type of containers received <br /> Date and Time Sample Put into Temp Storage Date: Z O Time: 13 <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) ETOn Both E]Not indicated <br /> If Sample ID's are listed on both COC and containers,do they all match? es ❑No ❑N/A <br /> Is the Project ID indicated: ❑On COC ❑On sample container(s) , �JOn 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? Yes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) la'6n Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? O'Ves ❑No ❑N/A <br /> COMMENTS: 6M& 1 LS V1 kN 4 -! 5+� !�j o� S <br /> L'Arr 4� (� lFl►'� c (WO a <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 69 of 69 <br />