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KIFFO REcervER <br /> Analvtical LLC SAMPLE RECEIPT CHECKLIST Initials <br /> SRG#: 7Z43q Date: O_Z �o <br /> Project ID: �T��_� <br /> Method of Receipt: Courier Over-the-counter Shipper <br /> COC Inspection <br /> Is COC present? 5;:Yes ❑No <br /> Custody seals on shipping container? ❑Intact ❑Broken ❑Not present-IN:IN/A <br /> Is COC Signed by Relinquisher? Yes ❑No Dated? 9Yes ❑No <br /> Is sampler name legibly indicated on OC? ❑Yes 5;�qo <br /> Is analysis or hold requested for all samples KYes ❑No <br /> Is the turnaround time indicated on COC? KYes F-1No <br /> Is COC free of whiteout and uninitialed cross-outs? ZYes ❑No, Whiteout ❑No, Cross-outs <br /> Sample Inspection <br /> Coolant Present: kYes ❑No(includes water) <br /> Temperature°C 2,.2— Therm. ID# Initial Ifl^,6�5 Date/Time 03L4/0 ) Z E]N/A <br /> Are there custody seals on sample containers? ❑Intact ❑Broken RNot present <br /> Do containers match COC? P,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 SgNo <br /> Are any sample containers broken, leaking or damaged? ❑Yes No <br /> Are preservatives indicated? ❑Yes,on sample containers Yes,on COC M Not indicated ❑N/A <br /> Are preservatives correct for analyses requested? WYes ❑No ❑N/A <br /> Are samples within holding time for analyses requested? KYes ❑No <br /> Are the correct sample containers used for the analyses requested? ZYes ❑No <br /> Is there sufficient sample to perform testing? g Yes ❑No <br /> Does any sample contain product, have strong odor or are otherwise suspected to be hot? ❑Yes ,R .,No <br /> Receipt Details <br /> MatrixContainer type Q #of containers received to <br /> Matrixtt Container type #of containers received_ <br /> Matrix Container type #of containers received <br /> Date and Time Sample Put into Temp Storage Date: 03?..q(U Time:__jy <br /> uicklo <br /> Are the Sample ID's indicated: ❑On COC ❑On sample container(s) 10 On 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 P;�.No ❑N/A <br /> Are the sample collection dates indicated: ❑On COC ❑On sample container(s) �n Both []Not indicated <br /> If collection dates are listed on both COC and containers,do they all match? Kxes ❑No ❑N/A <br /> Are the sample collection times indicated: ❑On COC ❑On sample container(s) 'jig:On Both ❑Not indicated <br /> If collection times are listed on both COC and containers,do they all match? ;.Yes ❑No EJ N/A <br /> COMMENTS: m1 , ��j,f�,Q 15 lVQIl4Cd -Gl "WS . _Pt'r 1 v y`�WvW.�- /u.vDP-i n1.t fzil,5 5)'I.'ac..V <br /> _�(ob,ele Ivt Wf U0 19,Per ID1114 14A45 o341/D ID3W <br /> �rt�eG� v.X So� specE6sc) t.1 <br /> _s <br /> bC- IAA6 03211tu 12-13 <br /> O:\old_ed\samprec\Forms\Sample Receipt Checklist rev 051409.doc <br /> Page 13 of 13 <br />