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Document Name: Dowment Revised:oaA�rtols <br /> h,�,,�te Sam k C�ditlon U on Recei Form Pa e i of 1 <br /> • '�'���`"'t" DocumentNo„ . � tssuingAuthority: <br /> FMN-L-213-►ev.16 Pece Minnesote Qual Otfice <br /> Client Wame: Project�: WO# : 1�358767 ; <br /> D�h' T�i(� ,iv�c � <br /> Courier. • (]fed 6c ❑UPS ❑USPS ent ' �"I,i I I I"i 1 �`"I�f I` <br /> (]Commerdal ❑pace ❑SpeeDee �Other, � 103g8787 <br /> ----�xaskingNamber-------. _..... _..___..... .. _..._.__._._. ---•— <br /> Custody Seai on Cooler/Box present7 DYes �No Sesls IrKectP QYea �No ��oaal: ProJ.Due Date: Proj.Name: ' <br /> Packin`Material: ❑8ubble Wrap []Bubble Bags �one ❑Other. 7emp Blenk7� DYes �o • <br /> «- ��,/// <br /> Thermometer _rJ�1401163 ❑B88A912t67504 Ty����: �yy� �81ue [�Norte ❑SempMs on ka,cooli <br /> USQd: �r 15340�64 ❑688N0143310098 ng praau hes begun <br /> Cooler Tamp R�d('�: _'r�q CoolerTemp Corrected('C): �•� B{ologlcol Tlawe Frozen7 DYes No A <br /> Temp shouid be sbove freezing to 6'C Correction Factor: k Date and lnitts{s of Pe►sort Examining Con�Ms: ! <br /> USDA Re;ulated Soil([]N/A,water sampie} <br /> Did samples origtnate In a quarantine zonewfthin the United States:AL,AR,AZ,U,f�,GA,1D, 3 Old samples origlnate from aforelgn source pnte►mti� <br /> M5,NC,NM,NY,OI(,OR,SG,7Tt,'fX or VA(theck maps)7 ❑Y2s o includlr�Hawaii and Puerto Rlco)i �Yas o <br /> !f Yes to elthar queatfon,flil out a Re;ulated 5oil Checkprt(F-M B)and include with SCURJCOC pspvw.ork. <br /> COMMEN`f5: <br /> Chain ofCusto Present7 . �s No N/a i, <br /> Chaln ofCVsto Fllkd Out? Yes No N A I. <br /> Chain ofCusto Reltn ulshed? y� � p q 3. <br /> Sam ler Name and/or Si ature on COC? ra wo n 4. <br /> Sam les Arrived with[n Hold Time7 Yea nb A 5. <br /> s1+ort Hdd nme Anai is <72 hr T Yes Mo N A 6, <br /> nush Tum Around TIrrK Ra uostad7 Y� p A 7, . <br /> SufficientVolume7 Yes No n 8. <br /> Correct Containers Used? res ❑Np �la/t/p 9. ' <br /> -Pace Contalners Used? res No �a/A <br /> Containers Int�Cti � Yes No N A 10. � <br /> Piltered Volume Received far Dissofved 7ests7 es roo n ii. Note if sediment is visible in the dissolved con�lner <br /> Sampfe labels Match COC? �f es ❑no ❑N/A 12. . <br /> ( <br /> -Includa Date/Time/ID/Arnal is Matrix: `1 <br /> Atl contafiers needing acid/base preservaUon have been 13. ❑HNOe ❑H�SO4 ❑NaOH ❑HCI <br /> chedced7` � �Yes �No �/A <br /> All coniainers needing preservatfon are fpund to be Sn r � Sampfe# <br /> comptiance wfth EPA reummendadon? . <br /> (HNO,,H:S�y HCf�2;NaOH>9 Sulfide,Na0l1>12 Cyanide) QYas ❑No A <br /> Exceptions:VOA,Col'rform,T0�Oil and Grease, Inklal when Lot#af added <br /> DRO 8015 water DOC Yes rro A com leted: reserv�tNe: <br /> Heads ce in VOA Vials >6rnm 7 Yes No N/A 14. <br /> Frlp Blank Preserrtl [�Yec (]No N/a 15. <br /> Trip BlankCustodySealsPresentl ❑Yes ❑Mo C�Y/A <br /> Pace Tri Blank Lot#(lf urchased): T <br /> e• u n ..n � a� n� nNa <br /> Person Contacted: p�rnm�; <br /> Comments/Resolutian: <br /> Project Manager Rev : '� � Dste: <br /> No�: Whenever there Is a disaepanry� l;ar01 ne compliarwe sampies,a oopy of this form wllt be seM to the Nortn Carolina DEHNR C�rtificadon Offfu(I.e out of <br /> hold,inwrrect preservative,out of temp,incorraat�ntslnera). <br /> Page 11 of 11 <br />