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Page 8 of 8 <br />AIWA <br />• <br />_. WORK ORDER #:06 <br />Cooler of <br />SAMPLE RECEIPT FORM <br />CLIENT:�F� <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 />3•\ 0 C Temperature blank. <br />°C IR thermometer. <br />Ambient temperature. <br />Initial: wt <br />CUSTODY SEAL INTACT: <br />Sample(s): Cooler: No (Not Intact) : Not Present: <br />Initial: <br />SAMPLE CONDITION: <br />Yes <br />No N/A <br />Chain -Of -Custody document(s) received with samples ......................... <br />. . . • <br />• • • • • • • • . • <br />Sampler's name indicated on COC ................................................. <br />Sample container label(s) consistent with custody papers ..................... <br />l .. • • <br />• • • • • • • • . <br />Sample container(s) intact and good condition ................................... <br />/ . • • <br />• • • • <br />Correct containers and volume for analyses requested ....................... <br />• . • <br />• • • • • • • • • . • <br />Proper preservation noted on sample labels ..................................... <br />...... <br />....... / <br />VOA vial(s) free of headspace........................................................ <br />...... <br />Tedlar bag(s) free of condensation................................................... <br />Initial: <br />COMMENTS: <br />