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DEC-11-2002 16.13 CALSCIENCE 714 894 7501 P 08/09 <br /> WORK ORDER#: 02-El 0 - El Ej ® E 1 <br /> � r � <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: t&K - f Jt�3s <br /> BATE: <br /> TEMPERATURE-SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY(Other than Calacience Couner): <br /> Chilled,cooler with temperature blank pnNIded _ *C Temperature blank <br /> - Chilled, cooler without temperature blankf, °C IR thermometer <br /> Chilled and placed In cooler with wet= Amtxent temperature <br /> Amblertt and placed in woler with wst lea <br /> Ambient temperature <br /> °C Temperature blank Initial* <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler No(Not Intact) Not Applicable(N/A) <br /> Initial 63�6vl <br /> SAMPLE CONDITION: <br /> acr . <br /> Yes No NIA <br /> Chain-Cf-Custody donent(a)received with samples ., .. <br /> Sample 00nt finer labels)consistent with custodypapers_ . —4� <br /> Sample container(s)Intact and good condition <br /> Correct containers for analyses requested / <br /> Proper preservation noted on sample label(s) <br /> _ _•.,, <br /> VOA viat(s)free of headspace •Y� <br /> Pedlar bag(s)free of condensation. <br /> Initial, 6-�Ir-- <br /> COMMENTS: <br />