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• Page 24 of 24 <br />WORK ORDER #:08 -E 0 - a a a �il <br />Cooler of <br />SAMPLE RECEIPT FORM <br />CLIENT: (!,P" A <br />TEMPERATURE - SAMPLES RECEIVED BY: <br />CALSCIENCE COURIER: <br />Chilled, cooler with temperature blank provided. <br />Chilled, cooler without temperature blank. <br />Chilled and placed in cooler with wet ice. <br />Ambient and placed in cooler with wet ice. <br />Ambient temperature. <br />°C Temperature blank. <br />DATE: L/ - 2-G' C;S <br />LABORATORY (Other than Calscience Courier): <br />°C Temperature blank. <br />-3,6 °C IR thermometer. <br />Ambient temperature. <br />Initial: 0 <br />CUSTODY SEAL INTACT: <br />Sample(s): Cooler: No (Not Intact) : Not Present: <br />Initial: <br />SAMPLE CONDITION: <br />Chain -Of -Custody document(s) received with samples ....................... <br />Sampler's name indicated on COC ................................................. <br />Sample container label(s) consistent with custody papers ................... <br />Sample container(s) intact and good condition .................................. <br />Correct containers and volume for analyses requested ....................... / ....... <br />Proper preservation noted on sample label(s)..................................... ....... <br />VOA vial(s) free of headspace........................................................ ....... <br />Tedlar bag(s) free of condensation................................................... ....... ....... / <br />Initial: '_N— <br />C@I*7tgh41AkRIII&-Yi <br />