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# # # # # # # # # # # # # # # # # # <br /> �7 eearnca <br /> jjgfFrrJrt�_Ti`t7nmari3aT WORK ORDER#: 07 - ❑) ❑a - ❑D ® N Q❑ <br /> i�t�t).OTa[SaYlesr lY]e. <br /> Cooler!of�_ <br /> SAMPLE RECEIPT FORM <br /> CLIENT: Y"(� rf DATE: 119 Q� <br /> TEMPERATURE—SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY(Other than Calscience Courier): <br /> Chilled,cooler with temperature blank provided. 3 r- °C Temperature blank. <br /> Chilled,cooler without temperature blank. —°ClRthermometer. <br /> Chilled and placed in cooler with wet ice. Ambient temperature. <br /> Ambien and placed in cooler with wet ice. <br /> Ambient temperature. <br /> °C Temperature blank. Inilial: . .'Ey/ <br /> °U <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No(Not lnwca) Net Present- <br /> Initial: 12 <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-Of-Custody document(s)received with samples,...................... ....... ....... <br /> Sampler's name indicated on COC...—........................................... ✓ ......._....... <br /> _ <br /> Sample container label(s)consistent with custody papers..................... ✓ ......._....... <br /> _ <br /> Sample containers)intact and good condition........ ................._. V ......._....... <br /> _ <br /> Correct containers and volume for analyses requested....................... \G......._....... <br /> _ <br /> Proper preservation noted on sample label(s)..._.__..........................._......._....... <br /> _� <br /> VOA vial(s)free of headspace.............._._._......__-...__.._.._......._....... ....... y <br /> Tedlar barks)free of condensation..................................................._......._....... ./ <br /> Initial: <br /> COMMENTS: <br />