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Document Name: Document Revised:25Feb2015 Sample Condition Upon Receipt Form Page 1 of 1 ACEAi all c?l Document No.: Issuing Authority: F-DAV-C-002-rev.02 Pate Davis,CA Quality Office �� Client Name: Pro'e t . .. .�. � �c�1 Wad : 1298347 ❑Courier: [-]Fed Ex CUPS ❑USPS 121dent 1111111111111111111111111 Commerc al ❑Pace ❑OnTrac []Other: - Tracking Number: 1288347 Custody Seal on Cooler/Box Present. ❑Yes VJNo Seals Intact? ❑Yes 4No Optional: Proj.Due Date Proj.Name: Packing Material: []Bubble Wrap ❑Bubble Bags L?flone ❑Other: Temp Blank? Dyes ,JNo Thermom.Used: V OA1434 ❑DA2285 Type of ice: 19Wet ❑Blue ❑DryIce ❑None ❑Samples on ice,cooling process has begun Cooler Temp Readd((°C): ��& Cooler Temp Corrected('C Biological Tissue Frozen? []Yes ❑No ZN/A Temp should be above freezing to 6'C Correction Factor: Date and Initials of Person Examining Contents: 0060 _ Comments: Chain of Custody Present? Yes ❑No ❑N/A 1. —i Chain of Custody Filled Out? res ONO ❑N/A 2. Chain of Custody Relinquished? []Yes ❑No ❑N/A 3. Sampler Name and/or Signature on C C? I[IYes ONO ❑N/A 4. Samples Arrived within Hold Time? IdYes [:]No ❑N/A 5. Short Hold Time Analysis(<72 hr)? rA. ❑No ❑N/A 6. Rush Turn Around Time Requested? ❑Yes VNo ❑N/A 7. •� Sufficient Volume? es ONO ❑N/A 8. a Correct Containers Used? Ates ❑Ne ❑N/A 9. z x Pace Containers Used? Oyes VNo ❑N/A JAN Containers Intact? 18 Yes ONO ❑N/A 10. Filtered Volume Received for D ssolved Tests? ❑Yes 0 N N/A 11. Note if se t i ' I in the dissolved container. Sample Labels Match COC? Oyes 0 N ❑N/A 12. v FlZALTH -Includes Date/Time/ID/Analysis tnx: St. C'—rl��r 1!iwiNT All containers needing acid/base preser/ation have been checked? ❑Yes ❑No 14N/A 13. ❑HNO3 ❑H1SO4 ❑NaOH ❑HCI All containers needing preservation are found to be in Sample# compliance with EPA recommendation. ❑Yes ONO VN/A (HNO3,H2SO4,HCI<2;NaOH>9 Sulfide,I JaOH>12 Cyanide) Exceptions:VOA,Coliform,TOC,Oil and Grease, initial when Lot#of added DRO/8015(water)DOC ❑Yes [ lo completed: preservative: Headspace in VOA Vials >6m m)? ❑YesNo ❑ /A 14. Trip Blank Present? ❑Yes ONO VfN/A 15. Trip Blank Custody Seals Present? ❑Yes ONO VIA Pace Trip Blank Lot#(if purchased): CLIENT NOTIFICATION/RESOLUTION Field Data Required? ❑Yes ❑No Person Contacted: Date/Time Comm a nts/Resolution: Project Manager Review: EN Date: 10/06/17 Note: Whenever there is a discrepancy ting Nort rolina compliance samples,a copy of this form will be sent to the North Carolina DEHNR Certification Office(l.e out of hold,incorrect preservative,out of temp,Incorre t containers) Page 14 of 26