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Laborato . <br /> 941 <br /> LLC; SAMPLE RECEIPT & REVIEW FORM <br /> Client: SDG/AR/COC/Work Order: <br /> Received By-A,— c..e nt Date Received: , <br /> 0Suspected Hazard Information o *If Net Counts>100cpm on samples not marked"radioactive",contact the Radiation Safety Group for further <br /> Z investigation. <br /> COC/Samples marked as radioactive? Maximum Net Counts Observed*(Observed Counts-Area Background Counts): ) <br /> Classified Radioactive lI or III by RSO? If yes,Were swipes taken of sample contatiners<action levels? <br /> COC/Samples marked containing PCBs? <br /> Package,COC,and/or Samples marked as <br /> beryllium or asbestos containing? XIf yes,samples are to be segregeated as Safety Controlled Samples,and opened by the GEL Safety Group. <br /> Shipped as a DOT Hazardous? Hazard Class Shipped: UN#: <br /> Samples identified as Foreign Soil? <br /> Sample Receipt Criteria Z Z Comments/Qualifiers(Required for Non-Conforming Items) <br /> Shipping containers received intact Circle Applicable: <br /> 1 and sealed? Seals broken Damaged container Leaking container Other(describe) <br /> 2 Samples requiring cold preservation Preservation Method: Ice bags Blue ice Dry ice None Other(describe) <br /> within(0<6 deg.C)?* all temperatures are recorded in Celsius <br /> Daily check performed and passed on Temperature Device Serial#: <br /> 2a IR temperature gun? C;1 / `y`' <br /> Secondary Temperature Device Serial#(If Applicable):/ , /' 6 <br /> +'�7"�y <br /> 3 Chain of custody documents included <br /> with shipment? X <br /> Circle Applicable: <br /> 4 Sample containers intact and sealed? Seals broken Damaged container Leaking container Other(describe) <br /> 5 <br /> Samples requiring chemical Sample ID's,containers affected and observed pH: <br /> preservation at proper pH? If Preservation added,Lot#: <br /> 6 <br /> VOA vials free of headspace(defined Sample ID's and containers affected: <br /> as<6mm bubble)? <br /> (If yes,immediately deliver to Volatiles laboratory) <br /> 7 Are Encore containers present? <br /> 8 <br /> Samples received within holding ID's and tests affected: <br /> time? <br /> 9 <br /> Sample ID's on COC match ID's on Sample ID's and containers affected: <br /> bottles? <br /> 10 Date&time on COC match date& Sample ID's affected: <br /> time on bottles? <br /> 11 <br /> Number of containers received match Sample ID's affected: <br /> number indicated on COC? <br /> 12 Are sample containers identifiable as <br /> GEL provided? X <br /> 13 COC form is properly signed in <br /> relinquished/received sections? <br /> Circle Applicable: <br /> 'FedEx Air FedEx Ground `UPS Field Services Courier Other <br /> 14 Carrier and tracking number. P¢, j J ` al �f��j( �1,�� Q/� Crlt)r A!,5 <br /> Comments(Use Continuation Form if needed): <br /> r <br /> PM(or PMA)review:Initials Date d, Page of <br /> Page 5 of 86 <br />