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r <br /> Page 12 of 12 <br /> WORK ORDER #: 07 - D - It T <br /> Cooler / of / <br /> SAMPLE RECEIPT FORM <br /> CLIENT: KIFF� DATE: 3 — )-7- 0 -7 <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. 2 °C Temperature blank. <br /> Chilled, cooler without temperature blank. °C IR thermometer. <br /> Chilled and placed in cooler with wet ice. Ambient temperature. <br /> Ambient and placed in cooler with wet ice. <br /> Ambient temperature. <br /> 'C Temperature blank. Initial: <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No(Not Intact) : Not Present: <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <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: <br /> COMMENTS: <br />