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PCIPNE <br /> 14021- <br /> MAR z 4 201 <br /> r-NVIR0N MENTAL HEALTh <br /> TestAmenoca riz�,�ITi E�o CES <br /> Sacramento <br /> Sample RPceivina Notes , <br /> THE LEADER IN ENVIRONMENTAL TESTING i� ,i <br /> i i II i I <br /> i I I II I11i11 <br /> Job:_ III II II. �i I I i� <br /> 320-24082�ieid Sheet ' <br /> Tracking d <br /> Use this form to record Sample Custody Seal,Cooler Custody Seal,Temperature&corrected Temperature&other observatlons. <br /> File in the job folder with the COC. <br /> Therm. ID 1Z I/ 13 I AK f Other <br /> Notes: L <br /> Ice '<Wet DryOther d <br /> Cooler Custody Seal - <br /> Sample Custody Seal: <br /> _ Cooler ID: <br /> Temp: Observed <br /> Corrected: U <br /> From:Temp Blank ❑ Sample <br /> NCM Filed: Yes 0 No 0 <br /> Yes No NA <br /> Perchlorate has headspace? ❑ D ,tj' <br /> CoC is complete w/o discrepancies? Zf ❑ D <br /> Samples received within holding time? pf D D <br /> Sample preservatives verified? D <br /> Cooler compromised/tampered with? ❑ "0 ❑ <br /> Samples compromised/tampered with? ❑ ) ❑ <br /> COC and Samples w/o discrepancies? P ❑ D <br /> Sample containers have legible labels? P ❑ ❑ <br /> Containers are not broken or leaking? )2( ❑ ❑ <br /> Sample date/times are provided. ❑ D <br /> Appropriate containers are used? ,� ❑ ❑ <br /> Sample bottles are completely filled? P' ❑ D <br /> Zero headspace?' ❑ ❑ 4 <br /> Multiphasic samples are not present? ❑ ❑ .d <br /> Initials: 0�x Date: (� <br /> -Containers roqulring zero nendspace Neve no headspace.or bubble<5 mm(1/47 <br /> L IQAIFORMSIQA-812 REV. 1-1 SAMPLE RECEIVING NOTES 2016-11-18.DOC OA-812 TGT 11/1x/2016 <br /> Page 25 of 26 12/8/2016 <br />