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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) 540-7111 email: smoRCdtsexa.gov <br />SAMPLE RECEIPT CHECKLIST <br />AuthorizationNumber(s):_ <br />ZOC--CatoS <br />20 Erb <br />10C <br />Date & Time Received: k131-10,21 <br />Q <br />2 ' Sc <br />am/e) <br />ro exly cora lated Chain-of-Custod ? <br />Sample Checklist Criteria: <br />the Sample Analysis Request (S.4R) form received with the samples) with a <br />ro exly cora lated Chain-of-Custod ? <br />2. Quantity of parcels received: 1 <br />MNoN/A1.4Yas <br />Observed Tem erature °C): Zb. L <br />3. Are sample conditions acceptable (intact and no damage)? <br />4. Are sample labels legible and agree with the SAR form? <br />5. Do the container size(s) received agree with the SAR form? <br />fit„ <br />6. Are custody seals present and intact for sample(s) submitted by OCI, EERD, or <br />✓ <br />HbGNIP? <br />Pmt <br />7. Sa nple(s) received in proper container(s)? <br />Fan <br />8. If VOC or GRO test method requested, are aqueous and liquid sample(s) received <br />✓ <br />without heads ace? <br />f*+ <br />9. If chemical preservation is required, are the sample(s) preserved properly? <br />1•w <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 />F" <br />11. <br />11. Does the requester information (charge codes, site location, etc.) on the ARF <br />✓ <br />T ree with the SAR form? <br />�� <br />12. 4Cas the prioritization list of Test Methods confirmed with the requestot•? (Refer <br />to PRM: 07.0162.00, Review of Requests, Proposals and Contracts Checklist)F"1 <br />NU 115: 1t samples were snipped, lmtral and nate each courier air bill/packing slip. <br />Any discussions associated with the above information were communicated to Requestor/Transporter: <br />In Pcrson: Date: (0 3 (2 By Phone:_ Date: By Email:_ Date: <br />Comments: <br />U�dst< Qr,ar,tVI&Inov 'Yo tl ey/ ,.lea 2) Fuk ZuoQ' My <br />=6„ftrM,•1 YkWb� sa.,P< laL,I far S�-6s6(Al an MSL S(AYW) vJAW VLI <br />Form Completed by: <br />Name: "7M m < rro Siguatu� Date, &/3/70( <br />i u <br />DCN: 07.0071.00—Revision 4-8/7/2020—Approved by QMO Page 1 of 1 Page 14 of 20 <br />