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-0Ci-2093 19�Z7CALSCIENCE ENVIRONMENTAL 714 894 '�1 P. <br /> ti 1 1S N: S <br /> JJ 1r e f "• <br /> 517R'i. YaA A 4 j <br /> 1111'ORK ORDER#. 03-0 M El 'E22 E [2 <br /> - <br /> Cooler� _ of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE: Z Z a <br /> TEMPERATURE WPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY{Other then Calsclence Courier): <br /> Chilled,cooler with temperature blank p}ravided °C Temperature blank <br /> Chilled,cooler without temperature blank. °C IR thermometer <br /> Chilled and placed in 000ler with wet lee Ambient temperature <br /> Ambient and placed in choler wdh wet km <br /> Ambient temperature. <br /> °C Temperature blink Initial. <br /> CUSTODY BEAL INTACT: , <br /> Sampli(s): Cooler ✓ No (Not Intact) Not Applicable(WA) <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No WA <br /> Chain-OF-Custody documengs)received wlfh samples lr ... ,..,... <br /> Sample oontalner labe(s)consistent with custody papers -- .,.,... ... .... <br /> Sample container(s)iniad and good condition ,. . . ... <br /> Correct containers for analyses requested— V ... .. <br /> Proper preservation noted on sample label(s) . .. ►/ ....... <br /> VOA via(s)free of headspace. . . .... .... . <br /> Tedlar b"(s)frre of condensation......... . . .,... ...... lr <br /> Initial <br /> COMMENTS: <br />