DEQ-CFW_00071334

i estAmerica
THE LEADER IN ENVIRONMENTAL TESTING
Shipping Order ID: 66124
smopme ome. Form - some ome.
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Ship To Information
Project Manager: Michelle Johnston
Company Name: NC-DWR
Attention:
Attn: Jim Gregson
Address 1:
127 Cardinal Drive Extension
Address 2:
Address 3:
City:
City: Wilmington
State:
NC
Zip:
28405
Phone #:
252-671-4778
Project Ref:
FAY-NC-DWR HFPO-DA SAMP
Notes to Bottle/Shipping Department
Please include coolers (2), cooler liners, custody seals, pre-printed
chains of custody (2), pre-printed labels, pre-printed FedEx return
labels for TA Denver, DI water (2 x 1 L bottles), and temperature
blanks.
Please relinquish the COCs.
Please label cooler "FAY - NC-DWR HFPO-DA SAMPLING'
Please send DI water in plastic non-teflon lined bottles.
Rush shipping charges will be billed on the next appropriate
invoice due to insufficient lead time.
Ship Via: FedEx Ground
Q Ready to Fill
R1 Seals on Coolers
❑ Seals on Bottle
❑ Bottle Sets
❑ Ice Cooler
TestAmerica Denver
4955 Yarrow Street
Arvada, CO 80002
Phone [phone] Fax [phone]
Due On: 7/18/2017 12:00:OOPM
0 Labels with Bottles
Q Preprinted
❑ Labels on Bottles
0 Preprinted COC
Please notify us immediately if an error is found in shipment
❑ Rebill Freight
[JJ Return Shipment Labels
Number of Return
Shipment Labels
(Prepaid Return)
Shipping Order ID: 66124
Page 1 of 3
Printed on 7/12/201712:34:55PM

Shipping Assets
Assets
I Quantity
Description
Filled
Blank labels
1
per container, pre-printed
❑
COCs
2
pre-printed, please relinquish
❑
Cooler liners
1
per cooler
❑
Coolers
2
total
❑
Custody Seals
2
per cooler
❑
DI Water
2
1 L bottles
❑
Pre-printed Fed Ex Labels
1
per cooler for TA DENVER
❑
Temperature Blanks
1
per cooler
❑
Please notify us immediately if an error is found in shipment
Shipping Order ID: 66124
Page 2 of 3
Printed on 7/12/201712:34:55PM

Bottle Order Information
Order Completion Information
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Bottle Order:
FAY-NC-DWR HFPO-DA SAMP
Bottle Order #:
22385
Request From Client: 711212017
Date Order Posted:
7/7/2017 10:15:46AM
Order Status.
Ready To Process
Prepared By:
Dylan Bieniulis
Deliver By Date:
7/18/2017 12:00:OOPM
Lab Project Number:
28016914
Creator: Dylan Bieniulis
Filled by:
Sent Date:
Sent Via:
Tracking #:
Sets
Bottles/Set
Qty
Bottle Type Description
Preservative Method
Matrix
Sample Type
Comments Lot #
12
2
24
1 Plastic 250ml - unpreserved
None
Water
Normal
HFPO-DA
Notes to Field Staff:
Health and Safety Notes:
Preservative Comment
Relinquished By
Company
Date
Time
Received By
Company
Seal #:
Seal #:
Seal #:
Seal #:
Relinquished By
Company
Date
Time
Received By
Company
Seal #
Seal #:
Shipping Order ID: 66124
Please notify us immediately if an error is found in shipment
Page 3 of 3 Printed on 7/12/201712:34:54PM

t
Approved Lot Numbers for Sample Bottles and Preservatives
TeStAmprica
7/10/2017 ESS,rretr.&DInraev911��s1MEMr.Q.VrrP.;
Container Type
Lot#
Preservative
Loi#
1 Gallon Amber4000-0250-QC
0103101C
Unpreserved
GallonCubitainer'3785-1030-QC
0320601Y' "
Unpreserved'
LNAI
1 L Amber 1000-0150-QC
01041016/0108201C
Hydrochloric Acid
4/56293
1 Liter Amber 1040 0150 4C
01041098 -
_ -.
Sodurfi Shi+3suffateT
D986f)(iDOd042857 .
1 Liter Amber 1000-0150-QC
0108201 C
Sulfuric Acid
0000161554
1 `Liter 4mt3er 1000150 {�C_
01D$201 C '
Unpreservep
TJA _ _ `. -
1 Liter Poly 1000-1901-QC
0206901C
Nitric Acid
0000162027/0000042514
1litetPolya00d990l-QC
012$901Z/0�09701",-SuthncAGd
- `bQQt)D5H`
I1000b16a55A`?
1 Liter poly 1000-1901-QC
0206901C
Upreserved
NA
1`25 mL Amber QC 0112"150..
0124401A_
Unpreserved '`
NA
125 mL Plastic 0125-1060-QC
0418201Y
Upreserved
NA
1-5mlLDPE;dropper;-QEC
091017-M2SfJ4
Sulfuric Acid ''
14978D .
15m1 LDPE dropper - QEC
051016-HCU041017-HCL
Hydrochloric Acid
132880/162118
15m1 LDPI<dropper:=i2EC
o,so,efam�u<,oar_ a±; ~avoo
NBie Acid -,
13399311$2027104917
16 oz Jar 0500-0015-QC
0110101Y
Unpreserved
NA
166 a_r0WbT0_4,QC'
0202501Y'-'
l�Opreserried
NFI
2 oz Jar 0060-0015-QC
0410101Y
Unpreserved
NA
25b m! Amber 0250 D1502C'.
04005U1►l0 0'h,
(il&iirochiorrcebcAcrd `
304028/703005
250 mL Amber 0250-0150-QC
04010501A/0308201C
Sulfuric Acid
0000161554
250 mL-AM bet.0250; 0150 QC_ _
03Q8201004D05U1'. _.
Uripreseri+ed .-: ;PIA
250 mL Poly NA
NOT IN USE
Sodium Hydroxide
NA
250 mL-Poly 0250-1901C
03139018
SulfwncAcid "
0000137221,E =
250 mL Poly 0250-1901-QC
0406901 C
Unpreserved
NA
260 mLfPolYfl250 aJ01 QC ' `
0069Q1GO;FAcata,
;
b000088705/fl0(1014482""'
25bmL-Poy.0250=1901 •-
0406901Cr000162b2
32 oz Jar 0950-0010-QC
0316901 B
Unpreserved
NA
4 of Jar D125 0055 QC "
0260018
fes
-
40 mL VOA 40AA-0300-QC
0213801 B
Ascorbic Acid
K39589
40 mL Y6A'40204035-QC ;
0122901 B '' . , _
t�J Water -
hfA
40 mL VOA 4025-300-QC
0219601 B
Hydrochloric Acid
56134/56293
40-mL-VOA'4006-5635 QC
D3229Q113
40 mL VOA 4049-5035-QC
0327101X
Sodium Bisulfate
143424
40 mL VOA 00A0=300aG1C ,
1j21380�$ :1
Sodium 7hIQsuffate
OgOQ152227_
40 mL VOA 0040-300-QC
0213801 B/013213801 B
Unpreserved
NA
fi0-m4 VaA 72fi0.0410 QC ,
02so Is�ln P 9.26s5379;
UnpaSetied ` '.. -
NA
40 mL VOA 0040-0410-QC
0119601 B
Unpreserved Amber
NA
500mL Arnbei.4500-0150aQC`
02D8201C _ ` _
Sulfunri AE(d
0000161554
500 mL Amber 0500-0150-QC
0405901 Y/0208201 C
Unpreserved
NA
500 mt Roty 0500-1901,-G3C --_
©2os2o-icro3aiisi��c/o3oezo�c
Nitrip Acid
00001620227t0050042514
500 mL Poly 0500-1901-QC
0306901C
Unpreserved
NA
60`MLVOA726M410-QC
0522601B/0522601A
Monochioroacetic40
304028/703005
8 oz Jar 0250-0055-QC
0226001 B/012801 C
Unpreserved
NA
8 oz, Poly Jar 0250-1041-QC
0234301Z
Unpreserved -
NA
En Core Sampler (En Novative)
14281
NA
NA
Sterile 125 mL Plastic (FISHER)
0009/0018 " `,
NA
NA'
Sterile 20 mL Syringe (FISHER)
6354862/6217791
NA
NA
Sterile 60 mL Syringe (Fisher)
6327$54
NA_
NA
Syringe filter, 0.2um Sterile (FISHER)
14616044/24616060
NA
NA
Syrirrge:Filter, 045pm (MG Scae_ntiflc) _
7006441
NA
NA
125ML 0125-2052-sp
1193422
NA
Trip Blank 4025-0300-QC
By Date
Hydrochloric Acid
ByDate
Trip Blank 0040-0300-QC
By Date
Sodium Thiosulfate
By Date
Trip Blank 0040-0300-QC
By Date
Unpr$served
By Date
4oz jar Amber _(Qe6) `
G-7=067-41DB
Unpreserved " '
NA- =
500ml Poly Amber 0500-1270-QC
0218201 Y
Unpreserved
NA
2506i1 Poly Amber 0250-1270-CSC"
0318201Y
Sodium Hydroxide
134482.
DF-F-0057-3-17-2017Rev 0
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Page 1 of 1 Bottle Prep Lot Numbers List_7-10-17
DEQ-CFW 00071337