COVEWFWP8 - Laserfiche WebLink

Home Browse Search

Document Name: Document Revised:14Nov2oi9 Sample Condition Upon Receipt Form Page 1 of 1 aceAllalytical• Document No.: Pace Analytical Services- F-MN-L-213-rev.30 Minneapolis Sam•on Receipt Condition• Client Name: _ Project#t W0# ; 10508446 1 Ca (\�) Courier: pM: JMG Due Date: 02/20/20 ]Fed Ex ❑UPS ❑USPS ❑Client UpRR Arcadia ElPace SpeeDee ❑Commercial See Exceptions CLIENT Tracking Number; �w �ij �j L� ❑ Custody Seal on Cooler/Box Present? 7c❑Yes ❑No Seals Intact? ©Yes ❑No Biological Tissue Frozen? ❑Yes ❑No [NN/A Packing Material: ❑Bubble Wrap [Bubble Bags ❑None &Other: Temp Blank? Yes ❑No Thermometer: ❑TI(0461) ®T2(1336)❑T3(0459) Type of Ice: Wet [:]BlueE]T4(0254) [71 T5(0489) ❑None ❑Dry [-]Melted 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): ❑see Exceptions Correction Factor: ' ' Cooler Temp Corrected w/temp blank: °C °C ❑i Container USDA Regulated Soil:(❑N/A,water sample/other: ) Date/Initials of Person Examining Contents:l:GIN 2- 2I f317.02U Did samples originate in a quarantine zone within the United States:AL,AR CA FL,GA, Did samples originate from a foreign source(int rnatlonally,Incl d g ID,LA.MS,NC,NM,NY,OK,OR,SC,TN,TX or VA(check maps)? ®Yes No Hawaii and Puerto Rico)? ❑Yes (Vo If Yes to either question,fill out a Regulated Soil Checklist(F-MN-Q-338)and include with SCUR/COC paperwork. COMMENTS: Chain of Custody Present and Filled Out? Elyes (-]No 1. Chain of Custody Relinquished? NYes [:]No 2. Sampler Name and/or Signature on COC? Yes ❑No C-]N/A 3. Samples Arrived within Hold Time? ( Yes []No 4. Short Hold Time Analysis(<72 hr)? ❑Yes ONo 5. ❑Fecal Coliform❑HPC❑Total Collform/E coli 0B0D/cB00❑Hex Chrome ❑Turbidity❑Nitrate❑Nitrite❑Orthophos❑Other Rush Turn Around Time Requested? jL,Yes ❑No 6. Sufficient Volume? ®Yes [-]No 7. Correct Containers Used? Pates ❑No 8. -Pace Containers Used? Res ❑No Containers Intact? 5LYes ❑No 9. Field Filtered Volume Received for Dissolved Tests? []Yes []No Ug N/A 10. Is sediment visible in the dissolved container?❑Yes ❑No Is sufficient information available to reconcile the samples 11. If no, write ID/Date/Time on Container Below: See Exception to the COC? NYes ❑No ❑ Matrix:❑Water Poll ❑Oil []Other All containers needing acid/base preservation have been ❑Yes ❑No ON/A 12.Sample# checked? All containers needing preservation are found to be in ❑Yes ❑No ; N/A ❑NaOH ❑HNO3 0112SO4 ❑Zinc Acetate compliance with EPA recommendation? (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 �KN/A Chlorine? ❑No pH Paper Lot# ❑ DRO/8015(water)and Dioxin/PFAS Res.Chlorine 0-6 Roll 0-6 Strip 0-14 Strip Extra labels present on soil VOA or WIDRO containers? ❑Yes .❑No /A 13. See Exception Headspace in VOA Vials(greater than 6mm)? ❑Yes ❑No EN/A ❑ Trip Blank Present? []Yes []No [AN/A 14. Trip Blank Custody Seals Present? ❑Yes ❑No N/A Pace Trip Blank Lot#(if purchased): CLIENT NOTIFICATION/RESOLUTION Field Data Required? ❑Yes ❑No Person Contacted: Date/Time: Comments/Resolution: Project Manager Review: Date: Note: Whenever there Is a discrepancy affecting North Carolina compliance samples,a copy of this form will be sent to the Nort Carolina DEHNR Certification Office(Le out of hold,Incorrect preservative,out of temp,Incorrect containers). Labeled by: G v v e 1 T-779