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Document Name: Document Revised:24Apr2017 Soil Checklist Page 1 of 1 8Cf'Altc311Cc7/ Document No.: Issuing Authority: F-DAV-C-028-Rev.02 Pace Davis Quality Office / / ) SOIL CHEM]"� j0�c. l7 Client: t�� 1��/ Work Order: Initials/Date: Are samples soil or other re ulated material? ❑ Yes ❑ No If no,matrix description: Sample Origin(circleone): FOREIGN (including non-continenra(U.S.) DOMESTIC If Foreign,list Cou of Or in: / (regulated,proceed to Requirements) D h M NY OR— Indicate County of Origin Site address r iusr be confirmed against quarantine areas in these states.If unknown,contact PM. Project connolie received until this is determined. If Domestic, circle State of samp es from a rantine zone? E] Yes (/No (If No,procee I with receipt samp es are not regulated,If yes,proceed to depth question.) Origin: ........._.__._...... ..._ ..___.._.__...... .___.__.... .... AL AR F L 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 depth 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 1 eet are Were samples segregated by depth<or>6 feet? YES NO N/A exempt from classification as regulated 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 to prevent and/or loose soil in the cooler)? accidental release. Anything that domes into If YES,were ice and melt water sterilized by adding enough bleach to YES NO N/A contact with loose soil must be treated as achieve a 10%concentration and sitting for>30 minutes before disposing. regulated. If YES,was any broken glass and/or loose soil placed in the USDA YES NO N/A Regulated soil drum or Regulated satellite container? Samples must be segregated and stored in Were samples placed in a designated container and cooler? YES NO designated bins and coolers. Yellow stickers identify regulated soil samples. Did yellow stickers get placed on all sample containers? YES NO Equipment and supplies that have come Into Were the cooler(s)and/orcountertop(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/P for Regulated Soils: Sample Analysis to be cond icted at(circle all that apply): Davis Subcontract Lab Name of Subcontract Lab(s): REQUIREMENT I ACTION COMPLETED USDA/APHIS rep must be infc rmed by email when Notification to Anthony Jackson,USDA APHIS regulated soils are received and prior 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 paperwork is YES NO N/A compiled.) Comments: Project Manager Signature: i C-1r R NJ�A1 ' "_"" 1T1_1 IENIJI j Df06�T7 W , DEC 202017 ENVIRONMENTAL HEALTH Page 15 of 26 DEPARTMENT