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Page 15 of 15 <br /> WORK ORDER #: 05 - E F91 - E F61 o a <br /> Cooler 4 of 1 <br /> SAMPLE RECEIPT FORM <br /> CLIENT• 1 ! DATE- <br /> TEMPERATURE — SAMPLES RECEIVED BY <br /> CALSCIENCE COURIER LABORATORY (Other than Calsdence 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 /> L_ _V_ <br /> CUSTODY SEAL INTACT <br /> Sample(s) Cooler No (Not Intact) Not Applicable(NIA) <br /> Initial <br /> SAMPLE CONDITION- <br /> Yes No NIA <br /> Chan-Of-Custody document(s)received with samples 1 <br /> Sample container label(s)consistent with custody papers —b- 1!`-r-- <br /> Sample container(s)intact and good condition <br /> Correct containers for analyses requested <br /> Proper preservation noted on sample labels) <br /> VOA vial(s)free of headspace t <br /> Tedlar bags)free of condensation L/ <br /> Initial <br /> COMMENTS. <br /> r <br />