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WORK ORDER #: 03 I®® - EH99 <br /> Cooler - - of <br /> SAMPLE RECEIPT FORM <br /> CLIENT- 161 E E DATE: � = 0S <br /> TEMPERATURE—SAMPLES RECEIVED BY• <br /> CALSCIENCE COURIER- LABORATORY(Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided 1f 'C Temperature blank <br /> Chilled, cooler without temperature blank °C IR thermometer <br /> Chilled and placed in cooler with wet ice Ambient temperature <br /> Ambient and placed in cooter with wet ice <br /> Ambient temperature <br /> °G Temperature blank Initial <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler ✓ No(Not Intact) Not Applicable (NIA) <br /> Initial <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of-Custody document(s) received with samples <br /> Sample container labef(s)consistent with custody papers <br /> Sample container(s)intact and good condition <br /> Correct containers 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 L� <br /> Initial <br /> COMMENTS: <br /> p <br />