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Document Name: Document Revised:25Feb2015 <br /> Sample Condition Upon Receipt Form Page 1 of 1 <br /> Document No.: Issuing Authority: <br /> F-DAV•C-002•rev.02 }Pace Davis,CA Quality Office <br /> Client Nam Project p: WO# • 1259806 <br /> Courier: ❑FedEx []UPS ❑USPS eclient III 11111 INIIN1111 11 111 <br /> ❑Commercial ❑Pate ❑OnTrac ❑Other 1259806 <br /> Tracking Number: -- <br /> ,.,+� <br /> Optional: Proj.Due Date: Proj.Name: <br /> Custody Seal on Cooler/Box Present? []YesQj No Seals IntattT ❑Yes �No <br /> Packing Material: ❑Bubble Wrap #]Bubble Bags ❑None rr-.//❑Other: Temp Blank? []Yes 21N <br /> Thermom.Used: ❑DA1434 F IDA2285 Type of Ice: I(lwet ❑Blue ❑Drylce ❑None ❑Samples on ice,cooling process has begun <br /> Cooler Temp Read('C): �O• Cooler Temp Corrected('C): Biological Tissue Frozen? []Yes []No 6N/A <br /> Temp should be above freezing to VC Correction Factor: 40r •ji Dat!and Initials of Person Examining Contents: <br /> I Comments: <br /> Chain of Custody Present? ,t.U/Yes No N/A I. <br /> Chain of Custody Filled Out? LOYes ONO ❑N/A 2. <br /> Chain of Custody Relinquished? Yes QNO ❑N/A 3. <br /> Sampler Name and/or signature on COC? byes ❑No N/A 4. <br /> Samples Arrived within Hold Time? Yes ONO ❑N/A 5. <br /> Short Hold Time Analysis <72 hr)? ❑Yes ANO ❑N/A 6. <br /> Rush Turn Around Time Requested? ❑Yes ZINo ❑N/A 7. <br /> Sufficient Volume? ) Yes ONO ❑N/A 8. <br /> Correct Containers Well Heyes ❑Np ❑NIA 9. <br /> re U <br /> -PaContainers Used? Yes ONO [_1 N/A <br /> Containers Intact? Yes ONO ❑N/A 10. <br /> Filtered Volume Received for Dissolved Tests? ❑Yes ONO ON/A 11. Note if sediment is visible in the dissolved container. <br /> Sample Labels Match COC? T-oves 0 N ❑N/A 12. <br /> -Includes Date/Time/ID/Analysis Matrix: / <br /> All containers needing acid/base preservation have been ❑Yes ONO ?N/A 13. ❑HNOa ❑H,SO. ❑NaOH ❑HCI <br /> checked? <br /> All containers needing preservation are found to be In Sample# <br /> compliance with EPA recommendation? ❑res ❑No N/A <br /> MND,H2504,HCI<2;NaOH>9 Sulfide,NaOH>12 Cyanide) <br /> Exceptions:VOA,Coliform,TOC,Oil and Grease, Yes ONO Initial when Lot#of added <br /> DRO/8015(water)DOC completed:_ preservative: <br /> Heads ace in VOA Vials >6mm? ❑Yes VNo N/A 14. <br /> Trip Blank Present? Oyes 0 N ❑N/A 15. <br /> Trip Blank Custody Seats Present? Dyes �No ❑N/A <br /> Pace Trip Blank Lot#(if purchased): <br /> CLIENT NOTIFICATION/RESOLUTION Field Data Required? ❑Yes ❑No <br /> Person Contacted: Date/Time: <br /> Comments/Resolution: <br /> roject Manager Review: 4"' P 4 ' Date: <br /> te: Whenever there is a discrepancy affeliting North Car Ilna compliance samples,a copy of this form will be sent to the North Caropna DEHNR Certification Office I Le out of <br /> old incorrect preservative,out of temp,Incorrect containers) <br /> Page 17 of 27 <br />