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WORK ORDER #: 04 -© U - HWNF2-1 <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: �F �►-aA�Y-"RC-Av- DATE: <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier), <br /> Chilled, cooler with temperature blank provided 4 3 °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. No(Not Intact) Not Applicable (NIA) <br /> Initial W <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) f <br /> VOA vial(s)free of headspace <br /> Tedlar bag(s)free of condensation <br /> Initial <br /> COMMENTS: <br />