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CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY <br />DEPARTMENT OF TOXIC SUBSTANCES CONTROL <br />Environmental Chemistry Laboratory -Berkeley <br />700 Heinz Avenue, Suite #150, Berkeley, CA 94710 <br />Phonc (510) 540-3111 email: smotlQdtsc.ca.gov <br />SAMPLE RECEIPT CHECKLIST <br />AuthorizationNumber(s): <br />Z13C-COWS" <br />! LoATrltoc <br />N/A <br />Init. <br />1.Was the Sample Analysis Request (SAR) form received with the sample(s) with a <br />properly completed Chain -of -Custody? <br />r/ <br />Date & Time Received: W <br />112021 <br />2. Quantity of parcels received: I <br />Observed Temperature 'C: 7.(v. G <br />© <br />2.1 SS <br />am/� <br />Sample Checklist Criteria: <br />Yes <br />No <br />N/A <br />Init. <br />1.Was the Sample Analysis Request (SAR) form received with the sample(s) with a <br />properly completed Chain -of -Custody? <br />r/ <br />2. Quantity of parcels received: I <br />Observed Temperature 'C: 7.(v. G <br />3. Are sample conditions acceptable (intact and no damage)? <br />Psn <br />4. Are sample labels legible and agree with the SAR form? <br />FM <br />6. Do the container size(s) received agree with the SAR form? <br />Fes+ <br />6. Are custody seals present and intact for sample(s) submitted by OCI, EERD, or <br />HWMP? <br />✓ <br />rry <br />7. Sample(s) received in proper container(s)? <br />Pu <br />8. If VOC or GRO test method requested, are aqueous and liquid sample(s) received <br />without heads ace?' <br />✓ <br />9. If chemical preservation is required, are the sample(s) preserved properly? <br />pw <br />10. Do the requested test(s) and/or number of samples listed on the Authorization <br />Request Form ARF meet or exceed those listed on the SAR form? <br />V/ <br />FM <br />11. Does the requester information (charge codes, site location, etc.) on the ARF <br />agree with the SAR form? <br />fM <br />12. Was the prioritization list of Teat Methods confirmed with the requestor? (Refer <br />to FRM: 07.0162.00, Review of Requests, Proposals and Contracts Checklist <br />VT <br />NOTE: If samples were shipped, initial and date each courier air bill/packing slip. <br />Any discussions associated with the above information were communicated to Requestor/Transporter: <br />In Person: ZDate: 6 02 1 By Phone:_ Date: By Email:_ Date: <br />ufd.t. rtenttaotroti 'f01) G rwded 11 Fuk 8son1My <br />Anfu-M&A VW61 Sa. B(a latul ( 5e-OnOsm an hn S(nmPk� �alaluvti, <br />Form Completed by: <br />Name: Signatu Date: Vygv21 <br />DCN: 07.0071.00_Revision 4_8/7/2020_Approved by QMO Page 1 of 1 Page 14 of 20 <br />