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� star WORK SJR ER M. 04 - <br /> Cooler ��-__ Of <br /> SAMPLE RECEIPT FORM <br /> cUENr.�--� - DATE• (�(-' - <br /> Fj <br /> EMPERATURE—SAMPLES RECEIVED BY:L$GtENCE <br /> COURIER-LABORATORY(Other than Caiscience Courier). <br /> Chill6d, cdoler with temperature blank provided 'C Temperature blank <br /> ChIlied, owler Without temperature blink. _ a C lit thermometer <br /> Chilled and placed In cooler vAth wet ICaa Atzibient temperature <br /> Ambient and placed in c4oler"th wet ice. <br /> Ambient temperature <br /> "C Ternpemture blanit, <br /> CUSTODY SEAL' INTACT: � -- <br /> Sarrl <br /> pie(4 Cooler:: too IN&intact): Not Applicable(tdlA _ <br /> SANIftE`C � - • <br /> OND�'ION; <br /> YeF No NIA <br /> Grain=Qf-Cur to,d <br /> ' j►tfQCt)rr18J7t(s)rrecetv!ed with . .- <br /> - papers...... . - <br /> S�rm`pf�`��net(s�`Cnte�,�tanif, <br /> 1 ��wf/4I I�.n.TT.TH,VwFay'hY y` •�..�y.y.- ) i.•.fro ♦1r aR.r <br /> hropgr pr�servat3on>n prl [i}t�_►abdi{Jy�lf. .. _..� <br /> -T.:�'}�. �4-"t 1-'I"�� s..wYI,.AK.rF.1 r.i F.aw:.'Y..1 Y51.• •a.a. •aa a <br /> VOA%ftl(s)free of headspapea .r... r... _ rK..... . .......... <br /> y ..}+a.r yF,r.r:..tira.i.vrr ..,L..i....-• •�r r.4�• .e�.1. �1 <br /> ) <br />