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a science <br /> ,rtirarrmsrst�t WORK ORDER #: 04 - "It`! - ®921 <br /> �bc�raatoril�s, fx>tc. �� v ---- ----- -� _-----__ - _.. ------ - - ----_ - - -— <br /> SAMPLE RECEIPT FORM E7 <br /> CLIENT: <br /> ,�frT DATE. <br /> TEMPERATURE -- SAMPLES RECEIVED BY- <br /> CALSCIENCE COURIER: LABORATORY (Other than Calsetence 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 v No(trot Intact) Not Applicable(N/A) <br /> Initial <br /> SAMPLE CONDITION* <br /> Yes No NIA <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 />