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�rrarr <br /> WORK ORDER #: 04 <br /> Cooler . I of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: PF- DATE: /, —P— r — <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calsclence Courier): <br /> Chilled, cooler with temperature blank provided ( ,j� "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.- _jgz No(Not Intact) Not Applicable (NIA) <br /> Initial �l.�i • <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Cham-Of-Custody document(s) received with samples —_I_ <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) - v— <br /> VOA vial(s)free of headspace — <br /> Tedlar bag(s)free of condensation <br /> Initial _ <br /> COMMENTS- <br /> . <br />