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TestAmen'bca <br />THE LEADER IN ENVIRONMENTAL TESTING <br />Sacramento <br />Sample Receivina Notes <br />Job:_ <br />320-24082 Feld Sneet <br />Tracking.. <br />Use this form to record Sample Custody Seal, Cooler Custody Seal, Temperature & corrected Temperature & other observations. <br />File in the lob roiaer wren me uv%,. <br />Notes: <br />Therm. ID 12 ! 13 / AK / Other <br />L <br />IceYVet_ DryOther <br />Cooler Custody Seal: --- <br />Sample Custody Seal: <br />-Cooler 1r)- <br />dTemp: Observed <br />Temp: <br />Corrected: u <br />From: Temp Blank ❑ Sample <br />NCM Filed: Yes ❑ No ❑ <br />Yes No NAA <br />Perchlorate has headspace? In ❑ A <br />CoC is complete w/o discrepancies? Zf ❑ ❑ <br />Samples received within holding time? 0(. ❑ ❑ <br />Sample preservatives verified?fat ❑ <br />Cooler compromised/tampered with? ❑ /42 ❑ <br />Samples compromised/tampered with? p )Mr ❑ <br />COC and Samples w/o discrepancies? �a ❑ ❑ <br />Sample containers have legible labels? /P ❑ ❑ <br />Containers are not broken or leaking? )2r ❑ ❑ <br />Sample date/times are provided. 06 ❑ ❑ <br />Appropriate containers are used? ,Ci ❑ ❑ <br />Sample bottles are completely filled? �' ❑ ❑ <br />Zero headspace?' ❑ ❑ 6' <br />Multlphasic samples are not present? ❑ p t� <br />Initials: Date: <br />'Containers requNing zero headspace have no headspace, or bubble < b mm (114 <br />r <br />L:IQA11FORMSIQA-812 REV. 1-1 SAMPLE RECEIVING NOTES 2016-11-18.DOC QA -812 TGT 1 1/1 812 01 6 <br />Page 27 of 28 12/9/2016 <br />113 <br />