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Laboratories LLC SAMPLE RECEIPT & REVIEW FORM <br /> Client: v -29KT SDG/AR/COC/Wo k Order: )�� <br /> Received By: iLyiDate Received: <br /> Suspected Hazard Information z *If Net Counts>100cpm on samples not marked"radioactive",contact the Radiation Safety Group for further <br /> investigation. <br /> COC/Samples marked as radioactive? IMaximurn Net Counts Observed*(Observed Counts-Area Background Counts): <br /> Classified Radioactive 11 or III by RSO? If yes,Were swipes taken of sample contatiners<action levels? <br /> COC/Samples marked containing I'CI3s? <br /> Package,COC,and/or Samples marked as <br /> beryllium or asbestos containing? f If yes,samples are to be segregeated as Safety Controlled Samples,and opened by the GEL Safety Group. <br /> Shipped as a DOT Hazardous? 'x' 1-Lazard Class Shipped: UN#: <br /> Samples identified as Foreign Soil? %�— <br /> Sample Receipt Criteria z Z Conuuents/Qualifiers(Required for Non-Conforming Items) <br /> Shipping containers received intact Circle Applicable: <br /> 1 and sealed? ag d Seals broken Dam ontainer Leaking container Other(describe) <br /> J\ <br /> 2 Samples requiring cold preservation Preservation Method: Ice bags Blue ice Dry ice None Other(describe) <br /> within(0<6 deg.C)?* x all temperatures are recorded in Celsius <br /> Daily Check performed and passed on 'temperature Device Serial#: + ���� ^Y n�� <br /> 2a IR temperature gun'? Secondary Temperature Device Serial#(If Applicable): I (^/T) <br /> 3 Chain of custody documents included <br /> with shipment? <br /> Circle Applicable: <br /> 4 Sample containers intact and sealed? Seals broken Damaged container Leaking container Other(describe) <br /> s Samples requiring chemical / Sample ID's,containers affected and observed pH: <br /> X\ <br /> preservation at proper pH? <br /> If Preqervation added.Lot#: <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 /> Samples received within holding ID's and tests affected: <br /> 8 time? r <br /> Sample ID's on COC match ID's on Sample ID's and containers affected: <br /> bottles? <br /> Ill Date&time on COC match date& Sample ID's affected: <br /> time on bottles? <br /> Number of containers received match Sample ID's affected: <br /> 11 number indicated on COC? <br /> Are sample containers identifiable as <br /> 12 GEL provided? <br /> 13 <br /> 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. <br /> 1 � c_l , <br /> Comments(Use Continuation Form if needed): <br /> a\ <br /> O <br /> PM(or PMA)review:Initials QP Date Page of <br />