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I <br /> l <br /> Document Name: Document Revised:2SFeb201S <br /> Sample Condition Upon Receipt Form Page 1 of 1 <br /> �^��,l"r",.,j• Document No.: Issuing Authority: <br /> r : <br /> F-DAV-C-002-rev.02 '•' } Pace Davis,CCA Quality Office <br /> 111111"M M. Client Name: v p ,1 r.-� Project#: r <br /> WO# • 12467 TO <br /> Courier: ❑Fed Ex ❑UPS V_IGY,V❑..JUUSSPISS &client 1111111111111111111111111 <br /> [-]Commercial ❑Pace ❑OnTrac ❑Other: 1246740 <br /> Tracking Number: L—__ <br /> Custody Seal on Cooler/Box Present? ❑Yes PNo ��'' Seals Intact? ❑Yes �No Optional: Proj.Due Date: Proj.Name: <br /> Packing Material: ❑Bubble Wrap ❑Bubble Bags %one ❑Other: Temp Blank? ❑Yes 04NO <br /> Thermom.Used: ❑DA1434 VDA2285 Type of Ice: ❑Wet ❑Blue ❑DryIce VNune ❑Samples on ice,cooling process has begun <br /> Cooler Temp Read('C): 23.f— Cooler Temp Corrected('Ci: Z-3. Biological Tissue Frozen? []Yes ❑ (� <br /> No N/A 1, <br /> Temp should be above freezing to 6'C Correction Factor: d Date and Initials of Person Examining Contents: cta7/S <br /> Comments: <br /> Chain of Custody Present? Yes ONO 0 N/A 1. <br /> Chain of Custody Filled Out? Yes ONO ❑N/A 2. <br /> Chain of Custody Relinquished? As ONO ❑N/A 3. <br /> Sampler Name and/or Signature on COC?_ es ONO ❑N/A 4. <br /> Samples Arrived within Hold Time? Yes ONO ❑N/A S. <br /> short Hold Time Analysis(<72 hr)? ❑Yes [2 No ❑N/A _6. <br /> Rush Turn Around Time Requested? ❑Yes Na ❑N/A 7. <br /> Sufficient Volume? _ Z,,,...JJJes ONO ❑N/A 8. - <br /> Correct Containers Used? I[JYes (�N/A 9. <br /> -Pace Containers Used? /❑Yes j7JNo ❑N/A <br /> Containers intact? res ❑No ❑N/A 10. <br /> Filtered Volume Received for Dissolved Tests? ❑Yes No o/A 11. Note if sediment is visible in the dissolved Container. <br /> Sample Labels Match COC? ,[]]No ❑N/A - <br /> ..�� <br /> -Includes Date/Time/ID/Analysis Matrix: I <br /> All containers needing acid/base preservation have been Oyes ONO (rN/A 13. ❑HNCj ❑HtSO. ❑NaOH ❑HCI <br /> checked? <br /> All containers needing preservation are found to be in Sample R t <br /> compliance with EPA recommendation? ❑Yes ONO �I/A <br /> (HIND,HzSO.,HCI<2;NaOH>9 Sulfide,NaOH>12 Cyanide) <br /> Exceptions:VOA,Coliform,TOC,Oil and Grease, s ONO Initial when Lot 0 of added <br /> DRO/8015(water)DOC _ completed:_ preservative: <br /> Headspace in VOA Vials(>6mm)? ❑Yei ONO ZN/A 14. <br /> Trip Blank Present? ElvesgNNo ❑N/A 15. -- <br /> Trip Blank Custody Seals Present? Ores ONO OK/A <br /> Pace Trip Blank Lot x(if purchased): _ <br /> CLIENT NOTIFICATION/RESOLUTION Field Data Required? ❑Yes []No <br /> Person Contacted: Date/Time: _ <br /> K:- <br /> comments/Resolution: <br /> Project Manager Review: u rn�. A. Dale: <br /> Note: Whenever there is a discrepancy affecting NOth Carolina compliance samples,a ropy of this form will be sent to the North Carolina DEHNR Certification office(i.e out of <br /> hold,incorrect preservative,out of temp,incorrect containers) <br /> Page 17 of 17 <br />