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Document Name: Document Revised:25Feb2015 <br /> 11 <br /> ce /• Sample Condition Upon Receipt Form Page Al'awai of i <br /> Document No.: Issuing Authority: <br /> F-DAV-C-002-rev.02 Pace Davis,CA Quality Office <br /> An I <br /> Client Name: Project#: WO 1259724 <br /> aJ�LJ7�C-- f} <br /> Courier: ❑Fed Ex ❑UPS ❑USPS Client II I II I I III I III'I I'll 11 III <br /> ❑Commercial []Pace ❑OnTrac ❑Other: <br /> Tracking Number: 1259724 <br /> Custody Seal on Cooler/Box Present? Dyes %No Seals Intact? ❑Yes tgNo Optional: Proj. Due Date: Proj.Name: <br /> Packing Material: ❑Bubble Wrap ❑Bubble Begs 1KNone ❑Other: Temp Blank? Dyes �ONo <br /> Thermom.Used: ❑DA1434 tg"2285 Type of Ice: Z'Wet('❑Blue ❑Drylce ❑None ❑Sampleson ice,cooling process has begun <br /> Cooler Temp Read('C): i,o t o Cooler Temp Corrected(T): I. , I^(S Biological Tissue Frozen? Dyes ❑No A/A <br /> Temp should be above freezing Correction Factor: }Q. _ Date and Initials of Person Examining Contents: 01311, <br /> Comments: <br /> Chain of Custody Present? es No ❑N/A 1 <br /> y�as . <br /> Chain of Custody Filled Out? ( .Yes JJNo N/A 2. <br /> Chain of Custody Relinquished? Yes QNO ❑N/A 3. <br /> Sampler Name and/or Signature on COC? Qyes Moo N/A 4. <br /> Samples Arrived within Hold Time? Yes ONO ❑N/A 5. <br /> Short Hold Time Analysis(<72 hr)? Dyes �/ o ❑N/A 6. <br /> Rush Turn Around Time Requested? ❑Yes I No N/A 7. <br /> Sufficient Volume? Yes ONO ❑N/A a. <br /> Correct Containers Used? Ayes ONO ❑N/A 9. <br /> • -Pace Containers Used? o ❑N/A <br /> Containers Intact? 16yes OND N/A 10. <br /> Filtered volume Received for Dissolved Tests? ❑res ❑NO N/A 11. Note if sediment is visible in the dissolved container. <br /> Sample Labels Match COC? 16yes ONO ❑N/A 12. <br /> -Includes Date/Time/ID/Analysis Matrix: W� <br /> All containers needing acid/base preservation have been yf _ <br /> checked? ❑Yes ❑NO [9N A 13. ❑HNOs ❑HISO. ❑NaOH []HCI <br /> All containers needing preservation are found to be Inesrs,�t{'' Sample x <br /> y <br /> compliance with EPA recommendation? Ores ❑No yry/A <br /> (HNO2,H2504.HCI<2;NaOH>9 Sulfide,NaOH>12 Cyanidel <br /> Exceptions:VOA,Coliform,TOC,Oil and Grease, bf Initial when Lot 8 of added <br /> DRO/8015(water)DOC rages ONO com leted: <br /> p preservative: <br /> Heads ace In VOA Vials(>6mm)? Dyes 14NO N/A 14. <br /> Trip Blank Present? Oyes ONO ❑N/A 15. <br /> Trip Blank Custody Seals Present? ❑Yes �!o ❑N/A <br /> Pace Trip Blank Lot x(if purchased): <br /> CLIENT NOTIFICATION/RESOLUTION Field Data Required? Dyes ❑No <br /> Person Contacted: Date/Time: <br /> Comments/Resolution: <br /> Project Manager Review: <br /> Date: t1frIt <br /> 6 <br /> te: Whenever there is a discrepancy affectln No hCarof ompliance Samples,a copy of this form will be sent to th North Carolina DEHNR Certification Office(i.e outof <br /> old,incorrect preservative,out of temp,Incorrect containers) <br /> Page 49 of 49 <br />