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5ZZMMQ=-WClient aurae: 610 Proj tlasAc ex Courier: ❑Fed Ex ❑UPS ❑USPS ❑Client ❑Commercial ❑Pace (ZOnTrac []Other: Tracking Number: f nflI n C ZQC <--2—, .7 P Custody Seal on Cooler/Box Present? ❑Yes VNo Seals Intact? Packing Material: ❑Bubble Wrap ❑Bubble Bags VINone []Other: Thermom. Used: 0 DA1434 ❑DA2285 Type of Ice: Owet Cooler Temp Read('C): V• � Cooler Temp Corrected(•C): �. Temp should be above freezing to 6'C Correction Factor: (0r e WO#:1263778 1111111!111111111111111 1263778 ❑Yes �No Optional: Proj. Due Date: Proj. Name: Temp Blank? ❑Yes Jallo ❑Blue ❑DryIce ❑None ❑Samples on ice, cooling process has begun Biological Tissue Frozen? ❑Yes []No [14/A Date and Initials of Person Examining Contents: IL I Chain of Custody Present? Document Name: Document Revised: 25Feb2015 ❑ N/A Sample Condition Upon Receipt Form Page 1 of 1 Document No.: Issuing Authority: No F-DAV-C-002-rev.02 Pace Davis, CA Quality Office 5ZZMMQ=-WClient aurae: 610 Proj tlasAc ex Courier: ❑Fed Ex ❑UPS ❑USPS ❑Client ❑Commercial ❑Pace (ZOnTrac []Other: Tracking Number: f nflI n C ZQC <--2—, .7 P Custody Seal on Cooler/Box Present? ❑Yes VNo Seals Intact? Packing Material: ❑Bubble Wrap ❑Bubble Bags VINone []Other: Thermom. Used: 0 DA1434 ❑DA2285 Type of Ice: Owet Cooler Temp Read('C): V• � Cooler Temp Corrected(•C): �. Temp should be above freezing to 6'C Correction Factor: (0r e WO#:1263778 1111111!111111111111111 1263778 ❑Yes �No Optional: Proj. Due Date: Proj. Name: Temp Blank? ❑Yes Jallo ❑Blue ❑DryIce ❑None ❑Samples on ice, cooling process has begun Biological Tissue Frozen? ❑Yes []No [14/A Date and Initials of Person Examining Contents: IL I Chain of Custody Present? Yes El No ❑ N/A 1. Chain of Custody Filled Out? []4es No ❑N/A 2. Chain of Custody Relinquished? Oyes (:1 No ❑N/A 3. Sampler Name and/or Signature on COC? Yes ❑No ❑N/A 4. Samples Arrived within Hold Time? Yes ❑No El N/A 5. Short Hold Time Analysis (<72 hr)? ❑Yes [XNo ❑N/A 6. Rush Turn Around Time Requested? ❑Yes No ❑N/A 7. Sufficient Volume? Q�Yes ❑No ❑N/A 8. Correct Containers Used? ZYes [:)No ❑N/A 9. Pace Containers Used? ❑Yes ONo ❑N/A Containers Intact? Vryes E] No ❑N/A 10. Filtered Volume Received for Dissolved Tests? ❑Yes ❑No 2� /A 11. Note if sediment is visible in the dissolved container. Sample Labels Match COC? ❑Yes E;Ko ❑N/A 12. ., Ct, Fti (/ i ", 6cc, G Includes Date/Time/ID/Analysis Matrix: ✓� /`te C.. 'oif �jj�-ems N fj 1b . All containers needing acid/base preservation have been checked? ❑Yes ONo U(N/A 13. ❑HNO, ❑H,SO, ❑NaOH ❑HCI All containers needing preservation are found to be in Sample # compliance with EPA recommendation? ❑Yes (:]No [aN/A (HNO,, H2SO,, HCI<2; NaOH >9 Sulfide, NaOH>12 Cyanide) Exceptions: VOA, Coliform, TOC, Oil and Grease, Dyes No Initial when Lot # of added DRO/8015 (water) DOC completed: preservative: Headspace in VOA Vials ( >6mm)? []Yes ❑No N/A 14. Trip Blank Present? ❑Yes ONo ❑N/A 15. Trip Blank Custody Seals Present? ❑Yes []No JZN/A Pace Trip Blank Lot # (if purchased): CLIENT NOTIFICATION/RESOLUTION Person Contacted: _ Comments/Resolution: Date/Time: Field Data Required? ❑Yes ❑No )� Project Manager Review: Date: Note: Whenever there is a discrepancy affectin North Carolina co fiance sa les, a copy of this form will be sent to th NortCarolina DEHNR Certification Office ( i.e out of hold, incorrect preservative, out of temp, incorrect containers) Page 26 of 26