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WORK ORDER #: <br /> > <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE:_ <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 Applicable (NIA): <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chaih-Of-Custody documents) received with samples......................... ��••- <br /> Sample container label(s)consistent with custody papers.................. .. . • <br /> Sample container(s) intact and good condition................................... ,�••, .- <br /> Correct containers for analyses requested...........:...... ... , V -••• <br /> Proper preservation noted on sample label(s)..................................... <br /> VOA vial(s)free of headspace. ....................................................... <br /> Tedlar bag(s)free of condensation............................ ••• ••• •• <br /> ..................... <br /> Initial: <br /> COMMENTS: <br />