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Document Name: Document Revised:23Aug2019 • Sample Condition Upon Receipt Form Page 1 of 1 aceAnalyticalDocument No.: Issuing Authority: F-MN-L-213-rev.29 Pace Minnesota Quality Office .• •Receipt Client Name: Project#: WO# : 10499008 i�=-,�1kusr� ks PM: JMG Due Date: 11/13/19 Courier: Li Ex ❑UPS ❑USPS []Client CLIENT: UPRR_Arcadis Pace ❑SpeeDee ❑Commercial see Exceptions Tracking Number: �C7y- '2�01 V,)qIlp ❑ Custody Seal on Cooler/Box Present? N(Yes ❑No Seals Intact? 0! i es ❑No Biological Tissue Frozen? ❑Yes ❑No A Packing Material: 44bble Wrap `qubble Bags ❑None ❑Other: Temp Blank? * ❑No Thermometer: ❑T1(0461) 2(1336)❑T3(0459) Type of Ice: ❑Wet []Blue [—]None ❑Dry ❑Melted ❑T4(0254) LJ T5(0489) Note:Each West Virginia Sample must have temp taken(no temp blanks) Temp should be above freezing to 6•C Cooler Temp Read w/temp blank: °C Average Corrected Temp (no temp blank only): ❑;xceptions Correction Factor: Cooler Temp Corrected w/temp blank: °C °C ❑ tainer USDA Regulated Soil:(❑N/A,water sample/Other: ) Date/Initials of Person Examining Contents: 2 Did samples originate In a quarantine zone within the United Statel:AL,AR,CA, GA, Did samples originate from a foreign source(Int rnationally,incng ID,LA.MS,NC,NM,NY,OK,OR,SC,TN,TX or VA(check maps)? e No Hawaii and Puerto Rico)? ❑Yes If Yes to either question,fill out a Regulated6ofi Checklist(F-MN-Q-338)and include with SCUR/COC pape o COMMENTS: Chain of Custody Present and Filled Out? bas []No 1. Chain of Custody Relinquished? nes ❑No 2. Sampler Name and/or Signature on COC? []Yes tao E]N/A 3. Samples Arrived within Hold Time? s [:]No 4. Short Hold Time Analysis(<72 hr)? ❑Yes0 5. []Fecal Coliform❑HPC -]Total Coliform/E coli❑BOD/cBOD[:]Hex Chrome ❑Turbidity[]Nitrate❑Nitrite❑Orthophos[]Other Rush Turn Around Time Requested? 110es []No 6. Sufficient Volume? Oes ❑No 7. Correct Containers Used? ge, []No 8. -Pace Containers Used? es ❑No Containers Intact? es [:]No 9. Field Filtered Volume Received for Dissolved Tests? ❑Yes []No WVA 10. Is sediment visible in the dissolved container?Dyes []No Is sufficient information available to reconcile the samples 11. If no, write ID/Date/Time on Container Below: see Exception to the COC? N�es ❑No ❑ Matrix:❑Water it ❑Oil ❑Other All containers needing acid/base preservation have been ❑Yes ❑No \O/A 12.Sample# checked? All containers needing preservation are found to be in ❑Yes ❑No C-"'/A E]NaOH ElHNO3 ❑H2SO4 ❑Zinc Acetate compliance with EPA recommendation? 1_ (HNO3,H2SO4,<2pH, NaOH>9 Sulfide,NaOH>12 Cyanide) Positive for Res.❑Yes See Exception Exceptions:VOA,Coliform,TOC/DOC Oil and Grease, []Yes ❑No */A Chlorine? [:]No pH Paper Lot# ❑ DRO/8015(water)and Dioxin/PFAS Res.Chlorine 0-6 Roll 0-6 Strip 0-14 Strip 13. See Exception Headspace in VOA Vials(greater than 6mm)? ❑Yes []No /A ❑ Trip Blank Present? ❑Yes [:]No /A 14. Trip Blank Custody Seals Present? [-]Yes []No LZIYA Pace Trip Blank Lot#(if purchased): CLIENT NOTIFICATION/RESOLUTION Field Data Required? Dyes ❑No Person Contacted: Date/Time: Com ments/Resol ution: Project Manager Review: Date: I I /12 /19 Note: Whenever there is a discrepancy affecting North Carolina compliance samples,a copy of this form will be sent to the North Carolina DEHNR Certification Office(Le out of hold,incorrect preservative,out of temp,Incorrect containers). Labeled by: Prl/n I /%/I _ .�of 1