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CAC <br /> inc <br /> WORK ORDER <br /> Cooler �1 ®f <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE: <br /> TEMPERATURE — AMPLES RECEIVED BY• <br /> CALSCIENCE COURIER: LABORATORY (Other than Calsclence Courier): <br /> Chilled, cooler with temperature blank provided �� °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 cooler with wet ice <br /> Ambient temperature <br /> °C 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 l� <br /> Sample container label(s) consistent with custody papers <br /> Sample container(s) intact and good condition V— <br /> Correct containers for analyses requested ✓ _ <br /> Proper preservation noted on sample label(s) <br /> VOA via!(s)free of headspace <br /> Tedlar bag(s) free of condensation <br /> Initial <br /> COMMENTS: <br />