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Page 1 ti} e u rof i n s WORK ORDER NUMBER: 17-06— I Calscience SAMPLE RECEIPT CHECKLIST COOLER ` OF CLIENT: D1Vr✓IF4 ID VWWjjZ0, S DATE: 06 / a 8 / 2017 TEMPERATURE: (Criteria: 0.0°C—6.0°C, not frozen except sedimenthissue) Thermometer ID:SC3B(CF: 0.0°C);Temperature (w/o CF): i-b °C(w/CF): 3- fi °C;011ank ❑ Sample ❑ Sample(s) outside temperature criteria (PM/APM contacted by: ❑ Sample(s) outside temperature criteria but received on ice/chilled on same day of sampling ❑ Sample(s)received at ambient temperature; placed on Ice for transport by courier 9q��,,,,� Ambient Temperature: ❑Air ❑ Filter Checked by:�"t CUSTODY SEAL: Cooler ❑ Present and Intact ❑ Present but Not Intact U of Present ❑ N/A Checked by: Sample(s) ❑ Present and Intact ❑ Present but Not Intact riot Present ❑ N/A Checked by: 21fL, SAMPLE CONDITION: Yes No N/A Chain-of-Custody(COC)document(s)received with samples................................................... �Z ❑ ❑ COC document(s)received complete ................................................................................. Ter ❑ ❑ ❑ Sampling date ❑ Sampling time [] Matrix ❑ Number of containers ❑ No analysis requested ❑ Not relinquished ❑ No relinquished date ❑ No relinquished time Sampler's name indicated on COC .................................................................................... jd- ❑ ❑ Sample container label(s)consistent with COC ..................................................................... Z' ❑ ❑ Sample container(s) intact and In good condition .................................................................. U/ ❑ ❑ Proper containers for analyses requested ........................................................................... —� ❑ EI Sufficient for analyses requested ..................................................................... Ld ❑ ❑ Samples received within holding time ................................................................................. J2( ❑ ❑ Aqueous samples for certain analyses received within 15-minute holding time ❑ pH ❑ Residual Chlorine ❑ Dissolved Suede ❑ Dissolved Oxygen .............................. ❑ ❑ 10, Proper preservation chemical(s) noted on COC and/or sample container.................................... Cl ❑ fa Unpreserved aqueous sample(s) received for certain analyses ❑ Volatile Organics ❑Total Metals ❑ Dissolved Metals Container(s)for certain analysis free of headspace ............................................................... ❑ ❑ ❑Volatile Organics ❑Dissolved Gases(RSK-175) ❑ Dissolved Oxygen(SM 4500) ❑Carbon Dioxide(SM 4500) ❑ Ferrous Iron(SM 3500) ❑ Hydrogen Sulfide(Hach) Tedlar`- bag(s)free of condensation ................................................................................. ❑ ❑ .� CONTAINER TYPE: (Trip Blank Lot Number: ) Aqueous: ❑VOA ❑VOAh ❑VOAna2 ❑ 100PJ ❑ 100PJna2 ❑ 125AGB ❑ 125AGBh ❑ 125AGBp ❑ 125PS ❑ 125PBznna ❑250AGB ❑250CGB ❑250CGBs ❑250PB ❑250PBn ❑500AGS ❑500AGJ ❑500AGJs ❑ 600PB ❑ 1AGB ❑ 1AGBna2 ❑ 1AGBs ❑ 1PB ❑ 1PBna ❑ ❑ ❑ ❑ Solid--, l4ozCGJ ❑8ozCGJ ❑ 16ozCGJ ❑Sleeve( ❑ Encoresa( ) ❑TerraCoreso( ) ❑ Air: ❑TedlerTM ❑ Canister ❑Scrbent Tube ❑PUF ❑ Other Matrix( 1: ❑ ❑ Container:A=Amber, B=Bottle,C=Clear,E=Envelope,G=Glass,J=Jar, P=Plastic,and Z=ZiploclResealable Bag Preservative:b=buffered,f=fiftered, h=HCI, n=HNOa, na=NaOH, nae=Na2S203.p=HRO.. Labeled/Checked by: , s=H2SO4,u=ultra-pure.a=Na2SO]+NaHSO..H20,znna=Zn(CH3CO2)2+NaOH Reviewed by: (OSj 2016-09-23 Revision