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Document Name: Revised Date: 15Feb2012 <br />aceAnalyttcal~ Sam le Condition U on Recei t Form Pa e 1 of 1 <br />_µ Document Number: Issuing Authority: <br /> F-MN-L-213-rev.02 Pace Minnesota Quality Office <br />Client Name: ~ r~sc~i .~ss~; Project # iD -U12~2'~ <br />Courier: ^ Fed Ex ^ UPS^ USPS^ Client^ Commercial ^ Pace Other e - ;~ ~ '~ ~ ~~ <br />Tracking #: (~d rf ~/ `f D 3 13 ~ ~ ~ 3 ~2) `~'.~~~ ~ ~~e~~te'` ~,fi ~ ; ~,~ ~~- <br />'?~~~) ~')~1Y1£ ~~ . <br />Custody Seal on Cooler/Box Present: ^ yes ~ no Seals intact: ^ yes [~'no ~ ~~ ~ `` Y' .-..:.~~ .~` .. r ~, .. - <br />Packing Material: ^ Bubble Wrap ^ Bubble Bags ^ None ^ Other Temp Blank: Yes ~ No <br />Thermometer Used 44~04~~80512447 Type of Ice: ~ Blue None ^ Sampres on ice, cooling process has begun <br /> <br />Cooler Temperature 1, ~} <br />Temp should be above freezing to 6°C Biological Tissue is Frozen: Yes No <br /> <br />Comments: Date and Initl I~ f ergo examining <br />contents• s <br />Chain of Custod Present: es ^No ^N!A 1. <br />Chain of Custod Filled Out: ~es ^No ^N!A 2, <br />Chain of Custod Relin wished: [lilYes ^No ^wA 3. <br />Sampler Name & Si nature on COC: l~es ^No ^N!A q, <br />Sam les Arrived within Hold Time: Yes ONo ^N/a 5. <br />Short Hoid Time Anal sis <72hr : ^Yes lNTio ^N/A 6. <br />Rush Turn Around Time Re wasted: ^Yes o DN/A 7. <br />Sufficient Volume: vas CINo ^wA g. <br />Correct Containers Used: <br />-Pace Containers Used: LYYes ^No <br />~5res ^No ^N/A <br />DN/A g. <br />Containers Intact: LtlYes ^No ^N/A 10. <br />Filtered volume received for Dissolved tests ^Yes ^No ~ 11. <br />Sample Labels match COC: <br />_.=lacludes_dateCtimeLlD(AnaL sis. _Matrix:__..._ ... L]lYes ^No <br />_:. _......._._... ^NIA <br />_.. 12. <br />. <br />All containers needing acidlbase preservation have been <br />checked. Noncompliance are noted in 13. <br />All containers needing preservation are found to be in <br />compliance with EPA recommendation. (HN03, <br />H2SO4, HCL<2; NaOH>12) <br />Oyes ^No <br /> <br />pYes ^No <br />NIA <br /> <br />~iiA HN03 <br />13. ^ <br />Samp # H2SO4 NaOH HCl <br />^ ^ O <br /> <br />Exceptions: OA oliform, TOC, Oil and Grease, WI-RRO (water) r~y~ <br />~ T Cs ^No Initial when /~, ) <br />Completed (~ ~/ Lot # of added <br />preservative <br />Headspace in VOA Vials (>timm : ^Yes t~lo ^N/A 14. <br />Trip Blank Present: <br />Trip Blank Custody Seals Present <br />Pace Trip Blank Lot # if purchased : ~ Y ~) Gres ^No <br />Comes ^No CIN/A <br />^N/A 15. <br />Client Notification! Resolution: Field Data Required? Y / N <br />Person Contacted: DatelTime: <br />Comments/ Resolution: <br />Project Manager Review: Date: ~~ ~ <br />Note: Whenever there is a discrepancy affecting North Carolina compliance samples, a copy of this form will be sent to the North Carolina DEHNR Certification <br />Office (i.e out of hold, incorrect preservative, out of temp, incorrect containers) <br />21 of 21 <br />