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WORK ORDER #: Q4 -aa - EPEE <br /> Inc_ Cooter of <br /> SAMPLE RECEIPT FORM <br /> CLIENTDATE. <br /> TEMPERATURE — SAMPLES RECEIVED BY <br /> CALSCIENCE COURIER- LABORATORY (Other than CaIscience 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 ��JJ <br /> °C Temperature blank Initial �[L_ <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler No(Nat Intact) Not Applicable (NIA) <br /> Initial <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-0f-Custody document($)received wcth 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 condensationy <br /> Initial <br /> COMMENTS: <br /> • <br /> 4 <br />