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Document Name: Document Revised:25Feb2015 <br /> Sample Condition Upon Receipt Form Page 1 of 1 <br /> ;aCeAW1yft >< Document No.: Issuing Authority: <br /> F-DAV-C-002-rev.02 Pace Davis,CA QLali y Office <br /> ConditionSample <br /> Upon Receipt Client Na?e. Cfy-c.'& &-.e,-Pro <br /> c WO## : 1298347 <br /> ❑Courier: Fed Ex ❑UPS ❑USPS Qruent II I II I'I II �I I�IIIII I I I III <br /> Commercial ❑Pace ❑OnTrac ❑Other: <br /> Tracking Number: 1298347 <br /> Custody Seal on Cooler/Box Present Dyes ZINO Seals Intact? ❑Yes 4No .1 Optional: Proj.Due Date. Proj.Name: <br /> Packing Material: []Bubble Wrap ❑Bubble Bags ONone QOther: Temp Blank? ❑Yes ,]No <br /> Thermom.Used: [5 DA1434 ❑DA228S Type of ice: VrWett !❑Blue ❑Dry Ice ❑None ❑Samples on ice,cooling process has begun <br /> Cooler Temp Readd((°C): 44.6 Cooler Temp Corrected(°C : ��T Biological Tissue Frozen? []Yes []No L&A <br /> Temp should be above freezing to 6'C Correction Factor: (�. Date and Initials of Person Examining Contents: 06 <br /> Comments: <br /> Chain of Custody Present? es ❑No ❑N/A 1. <br /> Chain of Custody Filled Out? Yes ❑No N/A 2. <br /> Chain of Custody Relinquished? [i yes ❑No ❑N/A 3. <br /> Sampler Name and/or Signature on C? 2 Yes ❑No []N/A 4. <br /> Samples Arrived within Hold Time? I/JYes ❑No ❑N/A 5. <br /> Short Hold Time Analysis(<72 hr)? Yes [JN- ❑N/A 6. <br /> Rush Turn Around Time Requested? ❑Yes [ifivo ❑N/A 7. <br /> Sufficient Volume? UKes ❑No ❑N/A 8. <br /> Correct Containers Used? [24es [:]No ❑WA 9. <br /> -Pace Containers Used? ❑Yes &mo ❑N/A <br /> Containers Intact? Ldyes ❑No ❑N/A 10. <br /> Filtered Volume Received for Dissoly Tests? ❑Yes [:]No N/A 11. Note if sediment is visible in the dissolved container. <br /> Sample Labels Match COC? Oyes ❑No ❑N/A 12. <br /> -Includes Date/Time/ID/Analysis atrix: <br /> All containers needing acid/base pres rvation have been <br /> checked? ❑Yes ❑No PN/A 1=. ❑HNO, ❑H,SO, ❑NaOH ❑HCI <br /> All containers needing preservation a e found to be in Sample P <br /> compliance with EPA recommendation? ❑Yes ❑No VN/A <br /> (HNO3,H2SO4,HCI<2;NaOH>9 Sulfide,NaOH>12 Cyanide) <br /> Exceptions:VOA,Coliform,TOC,Oil a d Grease, Initial when Lot it of added <br /> DRO/8015(water)DOC ❑yes Rx o com leted: <br /> P preservative: <br /> Headspace in VOA Vials(>6mm)? ❑Yes ONO /A 14. <br /> EPT.,"'cp <br /> Blank Present? ❑Yes ❑No VfN/A 15. <br /> Blank Custody Seals Present? ❑Yes ❑No [</A <br /> Trip Blank Lot k(if purchased): <br /> CLIENT NOTIFICATION/RESOLUTION Field Data Required? []Yes ❑No <br /> Person Contacted: Date/T,me <br /> Comments/Resolution: v 1, }r-�-- -- <br /> ENVIRONMENTAL HEALTH <br /> Project Manager Review: t Date: 10/0EDEPARTiMFNIT <br /> Note: Whenever there is a discrepancy t ng Nortrol!na compliance samples,a copy of this form will be sent to the North Carolina OEHNR Certification Office(I.e out of <br /> hold,incorrect preservative,out of temp,incorrect containers) <br /> Page 14 of 26 <br />