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s� <br /> WORK ORDER #: 03-0 El o Fol n d <br /> Cooler I Of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: 4DATE: 2 6r-�11 11 <br /> TEMPERATURE - SAM S RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided 1 °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 Manic Initial <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler No (Not Intact) <br /> Not Applicable (NIA) <br /> ZI <br /> Initial <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-Of-Custody document(s) received with samples (� <br /> Sample container label(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 <br /> Initial <br /> COMMENTS: <br />