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Page 8of8 <br /> • WORK ORDER #: 05 0 Fo� © E <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: t,-l; DATE:JZ, 2 1 ©_1; <br /> TEMPERATURE - SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER LABORATORY (Other than Calscience Courier) <br /> Chilled, cooler with temperature blank provided 6 0 'C Temperature blank <br /> Chilled, cooler without temperature blank °C IR thermometer <br /> Chilled and placed in cooler with wet tee 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 �r No(Not Intact) Not Applicable (NIA) <br /> • Initial <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Cham-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 />