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CALIFORNIA ENVIRONMENTAL. PROTECTION AGENCY <br />DEPARTMENT OF TOXIC SUBSTANCES CONTROL <br />Environmental Chemistry Laboratory -Berkeley <br />700 Heinz Avenue, Suite 4150, Berkeley, CA 94710 <br />Phone: (510) 540-3111 email: smofFQdtscxa.gav <br />SAMPLE RECEIPT CHECKLIST <br />Authorization Number(s): Z0C--eatoS , 2d pTa IOC <br />Date & Time Received: (P 13 I20 21 Q 2 t SS am/em <br />Sample Checklist Criteria: <br />Yes <br />1.Was the Sample Analysis Request (BAR) form received with the sample(s) with a <br />properly completed Chain -of -Custody? <br />✓ <br />ME <br />2. Quantity of parcels received: 1 <br />Observed Temperature ('C): Zb. <br />1Y <br />3. Are sample conditions acceptable (intact and no damage)? <br />f°N <br />4. Are sample labels legible and agree with the BAR form? <br />�M <br />5. Do the container size(s) received agree with the BAR form? <br />Fh <br />6. Are custody seals present and intact for samples) submitted by OCI, EERD, or <br />HWMP? <br />✓ <br />rN <br />7. Sample(s) received in proper container(s)? <br />F" <br />8. If VOC or GRO test method requested, are aqueous. and liquid sample(s) received <br />without head apace? <br />✓ <br />F. <br />9. If chemical preservation is required, are the sample(s) preserved properly? <br />fet <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 BAR form? <br />✓ <br />pM <br />11. Does the requester information (charge codes, site location, etc.) on the ARF <br />agree with the BAR form? <br />fM <br />12. Was the prioritization list of Test Methods confirmed with the iequestor? (Refer <br />to FRM: 07.0162.00 Review of Requests, Pro orals and Contracts Checklist) <br />NOLE; ac samples were snipped, antral and nate eacn courier air bLLUpacking slip. <br />Any discussions associated with the above information were communicated to Requestor/Pransporter: <br />In Person: /Date: (013f2&21 By Phone:_ Date: By Email:_ Date: <br />Comments: <br />upd.t.Qrbfrtr30hoN-to 1)Cykr.-Iea'21fti6Btoulmy <br />.6„ftrM'.( M65N( 50mfl. Ik4l &r S4'-6S13('o1 00 hn S�lrnpt� �Plaltillch <br />Form Completed by: <br />Name: Signaturc--� Date: L)Y/?0W <br />DCN: 07.0071.00—Revision 4_8/7/2020 Approved by QMO Page 1 of 1 Page 27 of 33 <br />