Form DPR-ENF-030 "Investigative Sample Analysis Report" - California

What Is Form DPR-ENF-030?

This is a legal form that was released by the California Department of Pesticide Regulation - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2016;
  • The latest edition provided by the California Department of Pesticide Regulation;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DPR-ENF-030 by clicking the link below or browse more documents and templates provided by the California Department of Pesticide Regulation.

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Download Form DPR-ENF-030 "Investigative Sample Analysis Report" - California

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State of California
Department of Pesticide Regulation
INVESTIGATIVE SAMPLE ANALYSIS REPORT
DPR-ENF-030 (Rev. 03/16)
Page 1 of 2
For Laboratory Use Only
LABORATORY NUMBER (Laboratory Use Only)
Important:
1. Use only one analysis report form per sample.
LABORATORY CONDUCTING ANALYSIS:
2. Complete chain of custody record on reverse.
ANAHEIM
3. Use black or blue ink--print legibly.
4. Original will be returned to the Analysis Requester.
SACRAMENTO
A. Sample Analysis Requester
AGENCY NAME (Complete name)
TELEPHONE NUMBER (Include Area Code)
FAX NUMBER (Include Area Code)
ADDRESS (Number and Street, City, State, ZIP Code)
E-MAIL ADDRESS (If results to be e-mailed)
B. Sample Source
PROPERTY OPERATOR / COMPLAINANT NAME
OPERATOR IDENTIFICATION/PERMIT NUMBER
TELEPHONE NUMBER (Include Area Code)
ADDRESS (Number and Street, City, State, ZIP Code)
SECTION, TOWNSHIP, RANGE
SITE IDENTIFICATION NUMBER
SAMPLE LOCATION (Address or Description)
COUNTY
C. Sample Information
SAMPLE CONSISTS OF:
COMMODITY/ACRES (If applicable)
SAMPLE IDENTIFICATION NUMBER
STRUCTURAL-RELATED
SAMPLE PRIORITY (Priority descriptions on reverse side of this form)
BASIS FOR SAMPLE (Check one box only)
#1
#2
#3
HEALTH HAZARD
ANIMAL ILLNESS/BEE LOSS
PLANT SYMPTOMS
ENVIRONMENTAL EFFECTS
YES
NO
YES
NO
CONTROL SAMPLE
COMPOSITE SAMPLE
YES
NO
SURFACE/SWAB
IF SURFACE/SWAB, INDICATE TOTAL SURFACE AREA:
SOLVENT USED:
YES
NO
DISLODGEABLE
IF DISLODGEABLE, INDICATE PUNCH SIZE/ # OF LEAF PUNCHES:
DESCRIPTION OF PROBLEM (Include DPR Tracking Number, if available)
SAMPLE COLLECTOR (Print name)
SIGNATURE
DATE SAMPLED
D1. Sample Discard Instructions
DISCARD DATE, IF DIFFERENT
Sample to be discarded 3 months after completion of analysis, unless instructed otherwise by the Requester.
D2. Sample Condition Upon Receipt (Laboratory Use Only)
SAMPLE CONDITION ACCEPTABLE:
IF UNACCEPTABLE, LIST REASON(S)
YES
NO
E. Laboratory Determination - Results relate only to the sample tested
ANALYSIS REQUESTED:
DET. CODE/
PESTICIDE DETECTED
AMOUNT
UNIT
DET. LIMIT
EXT. CODE
SPECIFIC PESTICIDE(S)
ANALYST
PESTICIDE SCREENS
(Specify below)
ANALYST
DATE ANALYSIS COMPLETED
REVIEWED BY
E-MAIL
FACSIMILE
VIA (Check one):
RESULTS FORWARDED TO
BY
DATE
TIME
(Over)
State of California
Department of Pesticide Regulation
INVESTIGATIVE SAMPLE ANALYSIS REPORT
DPR-ENF-030 (Rev. 03/16)
Page 1 of 2
For Laboratory Use Only
LABORATORY NUMBER (Laboratory Use Only)
Important:
1. Use only one analysis report form per sample.
LABORATORY CONDUCTING ANALYSIS:
2. Complete chain of custody record on reverse.
ANAHEIM
3. Use black or blue ink--print legibly.
4. Original will be returned to the Analysis Requester.
SACRAMENTO
A. Sample Analysis Requester
AGENCY NAME (Complete name)
TELEPHONE NUMBER (Include Area Code)
FAX NUMBER (Include Area Code)
ADDRESS (Number and Street, City, State, ZIP Code)
E-MAIL ADDRESS (If results to be e-mailed)
B. Sample Source
PROPERTY OPERATOR / COMPLAINANT NAME
OPERATOR IDENTIFICATION/PERMIT NUMBER
TELEPHONE NUMBER (Include Area Code)
ADDRESS (Number and Street, City, State, ZIP Code)
SECTION, TOWNSHIP, RANGE
SITE IDENTIFICATION NUMBER
SAMPLE LOCATION (Address or Description)
COUNTY
C. Sample Information
SAMPLE CONSISTS OF:
COMMODITY/ACRES (If applicable)
SAMPLE IDENTIFICATION NUMBER
STRUCTURAL-RELATED
SAMPLE PRIORITY (Priority descriptions on reverse side of this form)
BASIS FOR SAMPLE (Check one box only)
#1
#2
#3
HEALTH HAZARD
ANIMAL ILLNESS/BEE LOSS
PLANT SYMPTOMS
ENVIRONMENTAL EFFECTS
YES
NO
YES
NO
CONTROL SAMPLE
COMPOSITE SAMPLE
YES
NO
SURFACE/SWAB
IF SURFACE/SWAB, INDICATE TOTAL SURFACE AREA:
SOLVENT USED:
YES
NO
DISLODGEABLE
IF DISLODGEABLE, INDICATE PUNCH SIZE/ # OF LEAF PUNCHES:
DESCRIPTION OF PROBLEM (Include DPR Tracking Number, if available)
SAMPLE COLLECTOR (Print name)
SIGNATURE
DATE SAMPLED
D1. Sample Discard Instructions
DISCARD DATE, IF DIFFERENT
Sample to be discarded 3 months after completion of analysis, unless instructed otherwise by the Requester.
D2. Sample Condition Upon Receipt (Laboratory Use Only)
SAMPLE CONDITION ACCEPTABLE:
IF UNACCEPTABLE, LIST REASON(S)
YES
NO
E. Laboratory Determination - Results relate only to the sample tested
ANALYSIS REQUESTED:
DET. CODE/
PESTICIDE DETECTED
AMOUNT
UNIT
DET. LIMIT
EXT. CODE
SPECIFIC PESTICIDE(S)
ANALYST
PESTICIDE SCREENS
(Specify below)
ANALYST
DATE ANALYSIS COMPLETED
REVIEWED BY
E-MAIL
FACSIMILE
VIA (Check one):
RESULTS FORWARDED TO
BY
DATE
TIME
(Over)
INVESTIGATIVE SAMPLE ANALYSIS REPORT--CUSTODY RECORD
DPR-ENF-030 (Rev. 03/16)
Page 2 of 2
F. Sample Information
SAMPLE COLLECTOR (Print name)
SAMPLE IDENTIFICATION NUMBER
LABORATORY NUMBER (Laboratory Use Only)
G. Preservation Method During Transport
Ice
Dry Ice
"Blue" Ice
Cooler
Cool Dry Container
None
Other
H. Primary Sample Container Description
Paper bag
Plastic Bag
Glass Jar
Plastic Jar
Amber Jar
Other
I. Transport Information
NAME AND LOCATION OF COMMON CARRIER (If used)
REGIONAL OFFICE CONTACTED
W. Sacramento (NRO)
Clovis (CRO)
Anaheim (SRO)
(916) 376-8960
(559) 297-3511
(714) 279-7690
SHIPPING INVOICE NUMBER
DESTINATION
CA Dept. of Food and Agriculture
CA Dept. of Food and Agriculture
Sacramento Residue Laboratory
Anaheim Residue Laboratory
DOT NUMBER/CLASSIFICATION (If necessary)
3292 Meadowview Road
169 East Liberty Avenue
Sacramento, California 95832
Anaheim, California 92801
PH: (916) 262-1434
PH: (714) 680-7901
DATE SAMPLE SHIPPED
TIME
FAX: (916) 228-6876
FAX: (714) 680-7919
I certify that the above-listed sample is properly classified, described, packaged, marked, and labeled.
I additionally certify that this sample analysis is necessary in connection with matters relating to my official duties.
SAMPLE COLLECTOR (Print name)
SIGNATURE
DATE
J. Chain of Custody (Please sign)
RECEIVED FROM (Sample Collector)
DELIVERED TO
DATE
TIME (AM/PM)
STORAGE LOCATION
FOR SHIPPING
FOR STORAGE
1.
2.
FOR ANALYSIS
RECEIVED FROM
DELIVERED TO
DATE
TIME (AM/PM)
STORAGE LOCATION
FOR SHIPPING
FOR STORAGE
2.
3.
FOR ANALYSIS
RECEIVED FROM
DELIVERED TO
DATE
TIME (AM/PM)
STORAGE LOCATION
FOR SHIPPING
FOR STORAGE
4.
3.
FOR ANALYSIS
RECEIVED FROM
DELIVERED TO
DATE
TIME (AM/PM)
STORAGE LOCATION
FOR SHIPPING
FOR STORAGE
4.
5.
FOR ANALYSIS
RECEIVED FROM
DELIVERED TO
DATE
TIME (AM/PM)
STORAGE LOCATION
FOR SHIPPING
FOR STORAGE
5.
6.
FOR ANALYSIS
RECEIVED FROM
DELIVERED TO
DATE
TIME (AM/PM)
STORAGE LOCATION
FOR SHIPPING
FOR STORAGE
6.
7.
FOR ANALYSIS
For Sacramento Laboratory Use Only (When sample sent by common carrier): I certify that upon receipt, the package containing this sample received from the
common carrier was closed and sealed and there was no sign that the package was opened or otherwise tampered with prior to its delivery to or in the laboratory
receiving room.
SIGNATURE
DATE
SAMPLE PRIORITIZATION:
Priority 1: Samples where immediate preventative or remedial action can be taken to treat exposed persons or animals or to protect people from exposure.
Analysis goal for screens is 24 hours from receipt by the Laboratory. Specific analyses will take longer. Analytical results will be telephoned/faxed/e-mailed/mailed
to the requester. The original analysis report will be mailed to the requester.
Priority 2: Samples related to other human effects episodes identified as priority investigations. Analysis goal is 30 days. Specific analyses will take longer.
Analytical results will be telephoned/faxed/e-mailed/mailed to the requester. The original analysis report will be mailed to the requester.
Priority 3: Other evidentiary samples. Analysis goal is 90 days, however, workload generated by status samples 1 and 2 may impact completion date. Specific
analyses will take longer. Analytical results will be telephoned/faxed/e-mailed/mailed to the requester. The original analysis report will be mailed to the requester.
PROPER SAMPLE SIZE AND APPROVAL FOR ANALYSIS - Refer to the Evidence Collection section of the Investigation Procedures Standards Manual for
proper sample sizes. You must obtain approval from your DPR Enforcement Branch Liaison or regional office prior to submitting samples for laboratory
analysis.
ABBREVIATION OF TERMS:
DET. LIMIT=Detection Limit
07=GC/MS, Gas Chromatograph-Mass Spec. Single Quadrupole
EXT. CODE=Extraction Code
DET. CODE=Detection Code
35=GCMS/MS, Gas Chromatograph-Tandem Mass Spec.
805=QuEChERS Approach
01=ECD, Electron Capture Detector
52=LCMS/MS, Liquid Chromatograph-Tandem Mass Spec.
998=Single Analyte Extraction Method
02=FPD, Flame Photometric Detector
999=Original CDFA Extraction Method
DIAL 9-1-1 IN CASE OF ANY EMERGENCY
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