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• • Page 7 of 7 <br />WORK ORDER #:06 -E 0- © 0 HR <br />km Cooler of <br />SAMPLE RECEIPT FORM <br />CLIENT: T�FF �NA�YT�CA� <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: <br />LABORATORY (Other than Calscience Courier): <br />J• °C Temperature blank. <br />°C IR thermometer. <br />Ambient temperature. <br />Initial: W J <br />CUSTODY SEAL INTACT: <br />Sample(s): Cooler:_ No (Not Intact) : Not Present: <br />Initial: W� <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 />Yes <br />/ ....... <br />....... <br />....... <br />/ ....... <br />....... <br />....... <br />No N/A <br />...... . <br />....... <br />....... <br />....... <br />....... <br />....... <br />.. ....... <br />....... <br />Initial: <br />COMMENTS: <br />