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Page 7 of 7 <br /> r ,Gb. ratofr ai WORK ORDER #' 05 - O R] - 9 L�'J N [9 <br /> sbaYstnri�e,s. rna_ <br /> Cooler 1 of l <br /> SAMPLE RECEIPT FORM <br /> CLIENT. �-- DATE' <br /> TEMPERATURE —SAMPLES RECEIVED BY. <br /> CALSCIENCE COURIER: LABORATORY (Other than Calselence Courier) <br /> Chilled cooler with temperature blank provided �-�}_ O C Temmatura btank <br /> Chilled cooler w,thnet temperature blink s °C JR thermometer <br /> Chilled and placed in cooler with wet ice Ambient temperature <br /> Ambient and placed it,cooler with vvel Ice <br /> Ambient temperature <br /> a Temperature bran? lmval � <br /> CUSTODY SEAL INTACT: <br /> sample(s) Caroler � No(Not Intact) Not Applicable(NIA) <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 preservat nrt voted on sompts tahel(s). <br /> VCA vlal(,)free sof h-eadspace .... <br /> Tedlar bag(s)tree of condensation . , ... .. .... .f <br /> Inittal_ <br /> COMMENTS: <br />