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arnco <br /> WORK ORDER #: 04 -0D - EERIE <br /> bz�r�rro�►a$, lxra„ <br /> Cooler I of I <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE: LI_L 0_ _ _ <br /> TEMPERATURE —SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided L '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 ��e..� • <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of-Custody document(s) received with samples `LZ <br /> —Sample container laoel(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) LZ_ <br /> VOA vial(s)free of headspace ^_ <br /> Tedlar bag(s)tree of condensation (f <br /> Initial <br /> COMMENTS- <br />