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CALIFORNIA ENVIRONMENTAT, 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.oa.gov <br />SAMPLE RECEIPT CHECKLIST <br />AuthorizationNumber(s): ZO-CotoS'2dWrni c <br />Date & Time Received: ( Is 12a 21 Q_ 2 t SS am/ Si <br />pse Cnecansr Criteria: <br />�r�FFca, 1111;; <br />Yee <br />No <br />N/A <br />Init. <br />1 -Was the Sample Analysis Request (SAR) form received with the sample(s) with a <br />f <br />erl corn leted Chainof-Custod v <br />uantity of parcels received: 1 <br />rved Tem erature Pr \- Z G. 4 <br />- <br />1`k <br />re sample conditions acceptable (intact and no damage)? <br />e samplo labels legible and agree with the SAR form? <br />PN <br />psamplo <br />the container size(s) received agree with the SAR form?e <br />custody seals present and intact for samples) submitted by OCI, EERD, or' <br />mple(s) received in proper continer(?VOC <br />or GRO test method requested, are aqueous and liquid sample(s) received✓.out <br />heads acev <br />Fw•tchemical <br />preservation is required, are the sample(s) preserved properly? <br />Fw <br />o the requested test(s) and/or number of samples listed on the Authorization <br />est Form ARF meet or exceed those listed on the SAR form? <br />FM <br />11. Does the requestor information (charge codes, site location, etc.) on the ARF <br />✓ <br />a ee with the SAR form? <br />Pa'1 <br />12. Was the prioritization list of Test Methods confirmed with the requestor? (Refer <br />FRM: <br />to 07.0162.00, Review of Requests, Proposals and Contracts Checklist)F"1 <br />_ <br />Nf1TF.•TF�°mnle�.,.e.�..t:,.....a :r � <br />u sLa ..a.o each courier air ouupaeking slip. <br />Any discussions associated with the above information were communicated to Requestorrfransporter•: <br />In Person: Date: (o (612021 By Phone:_ Date: By Email:_ Date: <br />Comments: <br />'J?" a i'a i) Cywn,.tea 1) Fuk Btaosmy <br />.an flreAe.1 nest( Saa.Bl• Jk(eel f r S%0 -699("V OW1 ft1[. SmmOk) j0lalzlV4q <br />Form Completed by: <br />Name: - erbro L40-14 /V Signatu6:;;�— Date: (-/3/202( <br />DCN: 07.0071.00–Revision 4_8/7/2020–Approved by QMO Page 1 of 1 Page 27 of 33 <br />