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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 />Phone: (510) 540-3111 email: smoff@dtse.ca.gov <br />SAMPLE RECEIPT CHECKLIST <br />Authorization Number(s): <br />Z09 CQto$1?GAF610C <br />No <br />N/A <br />Init. <br />1.Was the Sample Analysis Request (SAR) form received with the sample(s) with a <br />Date & Time Received: k <br />13 <br />12021 <br />—@—!! <br />+ SS <br />am/6 <br />sample unecklist 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 />to erly com leted Chain-of-Custod -? <br />fm <br />2. Quantity of parcels received: 1 <br />�h <br />Observed Tem erature °C : ZG. L <br />3. Are sample conditions acceptable (intact and no damage)? <br />4. Are sample labels legible and agree with the SAR form? <br />Pti <br />5. Do the container sizes) received agree with the S.�R form? <br />�t,,t <br />6. Are custody seals present and intact for sartiple(s) submitted by OCI, EERD, or <br />/ <br />�s„r <br />HR MP? <br />V <br />�h <br />7. Sample(s) received in proper container(s)? <br />YM <br />8. If VOC or GRO test method requested, are aqueous and liquid samples) received <br />without head s ace? <br />Fes+ <br />9. If chemical preservation is required, are the sample(s) preserved properly? <br />f w <br />10. Do the requested test(s) and/or number of samples listed on the Authorization <br />Re uest Form ARF meet or exceed those listed on the SAR form? <br />Fay <br />11. Does the requester information (charge codes, site location, etc.) on the ARF <br />a ree with the SAR form? <br />f"7 <br />12. Was the prioritization list of Test Methods confirmed with the requester? (Refer <br />to FRM: 07.010'3.00, Review of Requests, Proposals and Contracts Checklist) <br />FM <br />NOTE If 1 <br />samp as 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 Pcrson: v� Date: % 3 02 By Phone:_ Date: By Email:_ Date: <br />Comments: <br />ufder. Qr'laertl3atu,v -Fa 1) cy a...etey 21 Fitt, Brwssay <br />.d„F,rmt�•1 Mews( Sn^+BI• Iw6,1 far 5�-65.6(901 av, h7L SCAWk) 1e1°1luvta <br />Form Completed by: <br />Name: IG ACCJ Signntu T Date: 31202f <br />DCN: 07.0071.00 Revision 4-8/7/2020—Approved Page 19 of 25 <br />_ by OMO Page 1 of 1 <br />