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CALIFORNIA ENVIRONMENTAI. PROTECTION AGENCY <br />DEPARTMENT OF TOXIC SUBSTANCES CONTROL <br />Environmental Chemistry Laboratory -Berkeley <br />700 Heinz Avenue, Suite #150, Berkeley, CA 94710 <br />Phene: (510) 540-3111 email: smof Ge dtse.ca.gov <br />SAMPLE RECEIPT CHECKLIST <br />Autho.Hzation Number(s): <br />Yes <br />No <br />NIA <br />Date &Time Received: <br />13 12.0 21 <br />✓ <br />am/Vm <br />Sample Checklist Criteria: <br />Yes <br />No <br />NIA <br />Init. <br />1.Was the Sample Analysis Request (S 4R) form received with the sample(s) with a <br />-properly completed Chain -o£ -Custody? <br />✓ <br />2. Quantity of parcels received: I <br />Observed Tem erature °C}: Z Co. C, <br />rot <br />3. Are sample conditions acceptable (intact and no damage)? <br />4. Are sample labels legible and agree with the SAR form?,�,t <br />5. Do the container size(s) received agree with the SAE form? <br />6. Are custody seals present and intact for sample(s) submitted by OCI, EERD, or <br />HWMP? <br />f <br />r <br />7. Sample(s) received in proper container(s)? <br />r„,t <br />8. If VOC or GRO test method requested, are aqueous and liquid sample(s) received <br />without head space? <br />f <br />9. If chemical preservation is required, are the sample(s) preserved properly? <br />fwi <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 />11. Does the requestor information (charge codes, site location, etc.) on the ARFf� <br />agree with the SAR form? <br />12. Was the prioritization list of Test Methods confirmed with the requestor? (Refer <br />to FRXI: 0-x.0162.00, Review of Requests, Proposals and Contracts Checklist <br />V/� <br />NOTE: if samples were shipped, initial and date each courier air billlpacking slip. <br />Any discussions associated with the above information were communicated to Requestor/Transporter: <br />In Pcrson: Z Date: (P3 02 By Phone: Date: By Email: Date: <br />Comments: <br />u�d4*� �-�ority�afi�ov� 'ra t� �.�e��•�dea 1) Fts4t ���asia►�/ <br />.6"f irme-( YWeC5%( Sao yl-, le -41 �6r S?- 6 s 05bi Gari N-9- sr Wlk) V111M VLj <br />Form Completed by: <br />Namc: crbres Signatu Date: 3120�2f <br />DCN: 07.0071.00—Revision 4_81712020 Approved by QMO Page 1 of 1 Page 6 of 26 <br />