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CALIFORNIA ENVIRONMENTAL PROTECTION AGENCY <br />DEPARTMENT OF TOXIC SUBSTANCES CONTROL <br />Environmental Chemistry Laboratory -Berkeley <br />700 Heinz Avenue, Suite 9150, Berkeley, CA 94710 <br />Phone: (510)540-3111 email: smoff@dtsc.ca.gov <br />dtsc.ca.gov <br />SAMPLE RECEIPT CHECKLIST <br />Authorization Number(s): <br />ZC C C o to S- <br />1 2a ATG <br />1oS T <br />Date &Time Received: W319 <br />T.Was the Sample Analysis Request (SAR) form received with the sample(s) with a <br />properly completed Chain -of -Custody? <br />-F21@ <br />2 16_S am/cm <br />2. Quantity of parcels received: 1 <br />Observed Temperature (°C): ZCv. L <br />Sample Checklist Criteria: <br />Yes <br />No <br />NIA <br />Init. <br />T.Was the Sample Analysis Request (SAR) form received with the sample(s) with a <br />properly completed Chain -of -Custody? <br />2. Quantity of parcels received: 1 <br />Observed Temperature (°C): ZCv. L <br />I�w <br />3. Are sample conditions acceptable (intact and no damage)? <br />f <br />4. Are sample labels legible and agree with the SAR form? <br />F►^� <br />5. Do the container size(s) received agree with the SAR form? <br />Ffin.► <br />6. Are custody seals present and intact for sample(s) submitted by OCI, EERD, or <br />HNVMP? <br />✓ <br />f7 <br />7.. Sample(s) received in proper container(s)? <br />f <br />r� <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 />stn <br />10. Do the requested test(s) and/or number of samples listed on the Authorization <br />Request Forza (ARF) meet or exceed those listed on the SAR form? <br />f <br />Fol <br />11. Does the requestor information (charge codes, site location, etc.) on the ARF <br />agree with the SAR form? <br />✓ <br />12. Was the prioritization list of Test Methods confirmed with the requestor? (Refer <br />to FRM: 07.0162.00, Review of Requests, Proposals and Contracts Checklist) <br />✓ <br />FAA <br />NOTE: if samples 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 Person: /Date: 60 S1202 L By Phone: Date: By Email: Date: <br />Comments: <br />u?dr, t -e Qr-t0rtt%:10-r10vt te, 1) cytw-k.leg 2) etsl,. !b►ac,5sC1y <br />6Y1�tfMc�� yVlt55+( <br />5a Ali-( <br />Form Completed by: <br />�_ �-'� r{o�ya.. 3202( <br />Name: 'i-1^[fNcrbcU a. -r Signatu : �_ ` Date: <br />