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INSTRUCTIONS FOR COMPLETING THIS FORM 1 Project Name/Number Record the name of the projector client/site location,and the billing number of the project(Example-613215,XYZ Chemical Co WA) Sample Team Members List the names of aU the members of the team taking these samples,team leader's name first Profit Center Number For intra company work,indicate the originating profit center number ' 4 Project Manager Record the project manager's name 5 Bill to Non-IT personnel should indicate the correct billing address and the person to whom the invoice should be sent IT personnel and IT subcontractors should fill in IT office responsible for project accounting(if known) 6 Purchase Order No Non-IT personnel should use this space to record the purchase order number authorizing the analysis of these samples IT personnel and IT subcontractors should leave this space blank if a project number has been given for billing 7 Samples Shipment Date Indicate the date these samples are shipped to the laboratory 8 Lab Destination Indicate the laboratory designated for sample shipment Do not list more than one lab on this form Be certain before sending samples that the laboratory you are designating is aware of the shipment and is capable of accepting these sample types and has available capacity 9 Lab Contact Give the name of the laboratory contact(typically the Lab Project Manager) 10 Send Lab Report to Give the name, address and phone number of the person to receive the data report for these samples 11 Required Report Date Record the date which you and the laboratory contact have determined the results will be reported(include verbal or final report as appropriate) 12 Project Contact/Phone Indicate the name of the project person to be contacted in case of any questions regarding these samples and the phone number where the contact may be reached the day the samples arrive in the laboratory ' 13 CarnerlWaybill Number If you are sending the samples by a commercial carrier such as Airborne or Federal Express,record the courier company name and the waybill or alrbrll number under which these samples will be shipped(Example- Fed-Ext#513631771) 14 Sample Number List the complete,unique,identification number of each sample These numbers must correspond with the identification numbers on the sample containers and the field sample collection document(s) 15 Sample Description/Type Provide a short physical description of the sample and the sample type such assail,sediment,sludge,water,wipe,air, concentrated waste or bulk 116 Date/Time Collected Record date and exact time each sample was collected Use a 24-hour clock,i e,1645 not 4 45 p m 17 Container Type Indicate the volume,color and type of the sample container used(Example- 1 gallon amber glass,1 liter clear plastic,40 milliliter clear glass) 18 Sample Volume Estimate the amount of sample in the container For air samples, indicate the volume of air sampled Preservation Indicate what type of preservative if any has been used#or the samples(Examples-ice to 4°C nitric acid hydrochloric acid) Requested Testing Program List the analyses to be performed on each sample by method number 21 Condition on Receipt Before a custody transfer,the intended recipient should verify all samples are present and in good condition This column may be used by the recipient to record any abnormalities found at the time of the transfer(Examples-jar lid cracked sample bottle leaking) 22 Disposal Record No Used by the laboratory to record requisite disposal information Not used when samples are returned to client 23 Special Instructions Use this space to record any special instructions to the lab regarding the processing of these samples 24 Possible Hazard Identification Indicate all hazard classes associated with the sample(s) 25 Sample Disposal Indicate how the samples should be disposed of following analysis All samples are held six weeks and then disposed of unless other arrangements for storage have been previously requested Lab will charge for packing,additional archiving and disposal 26 Turnaround Time Required Check"Normal"or"Rush' as determined by the Project Manager and the laboratory contact Rush samples are subject to a surcharge '27 OC Level These are ITAS QC levels and should not be confused with USEPA Analytical Levels Level I ITAS standard practice Use available analytical procedures Fifteen percent quality control (QC) samples (blank/spike/duplicate)for every20 samples QC samples may not be performed for a specific project but as part of compiled sets of samples QC data not reported ' with analytical results ITAS published rates apply to client samples tested Level II Use available analytical methods Fifteen percent QC samples minimum (blank/duplicate/spike or duplicate spike) QC samples are project or client-specific QC summary report include with analytical results No raw data are included Each QC sample billed as real analytical sample Level[It Uses referenced regulatory procedures and/or established/verified procedures using confirmatory techniques Method blank plus 20 percent or tow QC summary minimum per each matrix QC summary report supplied with supporting data Where applicable,this is USE PA Contract Laboratory Program(CLP)package Surcharge is added and/or QC samples are billed at sample rates Costs based _ on analytical program required �Prolect-specific Defined in QAPIP,Work Plan,or other specific plan or'procddure Project documentation must be submitted to the laboratory before beginning work Project requirements for QC samples cannot be less thah Level 1 28 Signatures` When releasing custody of these samples,use the"Relinquished By space to sign your full legal name,company name,date and time of release After verifying that all samples are present,the person receiving the samples must sign the Received By space to take custody of the samples 129 Comments Provide any additional explanatory information that may be required (Example-samples stored overnight in temperature controlled secure refrigerator) 886691