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- - WORK ORDER #:06-[E 9- 0 N RR <br />' Inc- Cooler I of I <br />SAMPLE RECEIPT FORM <br />CLIENT: <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: 121,2106 <br />LABORATORY (Other than Calscience Courier): <br />0 C Temperature blank. <br />° C IR thermometer. <br />CUSTODY SEAL INTACT: / <br />Sample(s): Cooler: V No (Not Intact) : <br />SAMPLE CONDITION: <br />Ambient temperature. <br />Initial: <br />Not Present: <br />Initial: <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 />....... ...... . <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 />COMMENTS: <br />................ 1 ........ <br />............... 1/....... <br />................. ....... ...... <br />................. t/ <br />Initial: 0157 <br />