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06!25/2006 20:24 713-241 <br />��►aal+tf+�r <br />EQUILON JENA PAGE 17 <br />Page is of is <br />WORK ORDER #: <br />Cooler of <br />SAMPLE RECEIPT FORM <br />CLIENT:DATE: - �{ <br />TEMPERATURE—SAMPLES RECEIVED BY: <br />CALSCIENCE COURIER: <br />01illed, Cooler +Mthtam paraaure blank provided. <br />ChIlled, cooler without temperature blank. <br />Chilled and pieced In coder with wet Ica. <br />Ambient and placed In cooler with wet ice. <br />Ambient temperature. <br />LABORATORY (Other than Calscietsce Courier): <br />---��-- °C Taarnperatum blank. <br />"tom °C A thermometer. <br />Ambient temperature. <br />° C Temparature blank. I nt W <br />CUSTODY SEAL IMPACT: <br />Sample(s)- Coder No (Not Intact) : Not APplicable (NIA): ` <br />. Irtltial' �� <br />SAMPLE CONDITION: <br />Yes No NIA <br />Choin-Of-Custody documents) receNed with semples.................. l <br />Samlple contalner labels) consistent with custody <br />Sample container(s) Intact and good condltlon...................... <br />Correct containers for analyses requested... <br />Proper Preservation noted on sample label(s) ................................ <br />VOA vial(s) Free of headspaace, ,..... .... . <br />Tedlar bags) ll ew of condensation....... ..... ,.,....+....., '. . ... _ <br />initial: <br />COMMENTS: <br />6T 'd aGLaa9irsoa SFt sganPnJd T TO T IauS jpO:aT 900a Se unr <br />