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Document Name: Document Revised:24Apr2017 Soil Checklist Page 1 of 1 aceAMIJdiCa Document No.: Issuing Authority: F-DAV-C-028-Rev.02 Pace Davis Quality Office / 'Q SOIL CHE Client: t.f/ (4fc-4v&C Work Order: �� Initials/Date: - f 17 Are samples soil or other re ulated material? ❑ Yes ❑ No If no,matrix description: Sample Origin(circle ne): FOREIGN (including non-continental U.S.) DOMESTIC If Foreign,list Co u of Or gin: (regulated,proceed to Requirements) C D M NY OR- Indicate County of Origin If Domestic, Site address ust be confirmed against quarantine areas in these states.If unknown,contact PM. Project canna a received until this is determined. circle State of samp es from a rantine zone? ❑ Yes VNo (If No,procee with receipt camp s are not regulated,If yes,proceed to depth question.) Origin: - _._..._.. _................__........._.................._.__....- _...... AL AR F GA LA MS NC OK SC TN TX VA (Regulated,proceed to depth question) ❑ NONE OF THE ABOVE (Proceed to receipt samples are not regulated.) Are any samples from a dep h of<6 ft? ❑ Yes ❑ No ❑ Not indicated Is sub analysis requested? ❑ Yes ❑ No (If No to both questions,proceed to receipt samples are not regulated.) REQUIREMENT ACTION COMPLETED Domestic soils from a depth of>6 fe et are Were samples segregated by depth<or>6 feet? YES NO N/A exempt from classification as regu Iz ted soil per California APHIS/USDA guidelines. If samples are to be subcontracted outside of California,treat sub samples as regulated soil. Were there any signs of breakage or leakage(check for broken glass YES NO Samples must be double contained o prevent and/or loose soil in the cooler)? accidental release. Anything that cc mes into If YES,were ice and melt water sterilized by adding enough bleach to YES NO N/A contact with loose soil must be trea ed as achieve a 30%concentration and sitting for>30 minutes before disposing. regulated. If YES,was any broken glass and/or loose soil placed in the USDA Regulated soil drum or Regulated satellite container? YES NO N/A Samples must be segregated and st red in Were samples placed in a designated container and cooler? YES NO designated bins and coolers. Yellow stickers identify regulated soil o samples. Did yellow stickers get placed on all sample containers? YES NO Equipment and supplies that have cc me Into Were the cooler(s)and/or countertop(s)decontaminated using a fresh contact with samples must be decontaminated 10%bleach solution? Were gloves,disposable lab supplies or shipping YES NO or disposed of properly. materials disposed of in the SR USDA Regulated satellite container? To Be Completed by PM/PC or Regulated Soils: Sample Analysis to be conduted at(circle all that apply): Davis Subcontract Lab Name of Subcontract Lab(s): REQUIREMEh T ACTION COMPLETED USDA/APHIS rep must be inforr ied by email when Notification to Anthony Jackson,USDA APHIS regulated soils are received and rior to shipping to PPQ indicated on California Regulated Soil Notification YES NO any subcontract lab,including IR Pace Labs. form. Sub shipments must include a valid copy of the is a copy of all needed paperwork included with the COC? receiving lab's permit along with all required forms. (SR cannot ship samples until all necessary pap f1work-ts— N A corn iled.) 'B - Comments: ,JAN i82018 Project Manager Signature: t �ENfJI � 4 DaCNI1R0N�7':NTAL HEALTH Page 15 of 26