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TestAmedca <br />THE LEADER IN ENVIRONMENTAL TESTING <br />Sacramento <br />Sample RPceivina Notes <br />Job:_ <br />320-24082 F eid Sheet <br />Tracking .. _ <br />Use this form to record Sample Custody Seal, Cooler Custody Seal, Temperature & corrected Temperature & other observations. <br />File in the lob toloer wim me uvu. <br />Notes: <br />Therm. ID 0,12/ 13 / AK / Other <br />Ice Wet _ DryOther <br />Cooler Custody Seal: -�- <br />Sample Custody Seal: <br />.Cooler 12_- <br />Temp:Observed �) <br />Corrected: > u <br />From: Temp Blank ❑ Sample <br />NCM Filed: Yes ❑ No ❑ <br />Yes No tLA <br />Perchlorate has headspace? ❑ D <br />CoC is complete w/o discrepancies? 4!r ❑ ❑ <br />Samples received within holding time? R ❑ ❑ <br />Sample preservatives verified? ❑ )a <br />Cooler compromised/tampered with? ❑ /P ❑ <br />Samples compromised/tampered with? D 'Ia- ❑ <br />COC and Samples w/o discrepancies? ? ❑ ❑ <br />Sample containers have legible labels? /0 ❑ ❑ <br />Containers are not broken or leaking? )2{ D ❑ <br />Sample date/times are provided. ,d ❑ ❑ <br />Appropriate containers are used? ,6 ❑ ❑ <br />Sample bottles are completely filled? 9' ❑ D <br />Zero headspace?' ❑ ❑ <br />Multiphasic samples are not present? ❑ ❑ .d <br />Initials: _Date: <br />'Comalners requMnp zero headspace have no headspim, or bubble < b mm <br />_ <br />iIJEE 0 7 2016 <br />L'IQAIFORMSIQA-812 REV. 1-f SAMPLE RECEIVING NOTES 2016-11-18.DOC 1 QA -812 TGT 11/18/2016 <br />Page 25 of 26 12/8/2016 <br />F13] <br />