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Page 7 of 7 <br />WORK ORDER #:06 -El 4- H❑3 RR <br />Cooler \ of \ <br />SAMPLE RECEIPT FORM <br />CLIENT: ��PP Pt�A�YC�CAL <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 />`� • ° C Temperature blank. <br />°C IR thermometer. <br />Ambient temperature. <br />Initial: Wyb <br />CUSTODY SEAL INTACT: <br />Sample(s): Cooler: No (Not Intact) : Not Present: <br />Initial: W\5 <br />SAMPLE CONDITION: <br />COMMENTS: <br />Yes <br />No N/A <br />Chain -Of -Custody document(s) received with samples ......................... <br />l ....... <br />....... <br />Sampler's name indicated on COC ................................................. <br />....... <br />....... / <br />Sample container labels) 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 />1--� ....... <br />Proper preservation noted on sample label(s)..................................... <br />....... <br />....... / <br />VOA vial(s) free of headspace........................................................ <br />....... <br />....... <br />Tedlar bag(s) free of condensation................................................... <br />....... <br />Initial: <br />COMMENTS: <br />