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RPR-11-2003 10 04 P 08 <br /> 4 <br /> WORK ORDER ® - El © 0 [2- <br /> ..�, #: O�- <br /> Cooler . (o# <br /> SAMPLE RECEIPT FORM <br /> CLIENT: �r�` DATE: <br /> TEMPERATURE— SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER., LABORATORY (Other than Calsclence Courier. <br /> Chilled.cooter with temperature blank provided_ °C Temperature blank. <br /> Chilled,cooler without temperature blank °C IR thermometer <br /> Chilled and placed in cooler vAth wet ace Ambient temperature <br /> Ambient and placed in cooler with wet Ice <br /> Ambient temperature <br /> OC Temperature blank. Initial. <br /> —.j <br /> CUSTODY SEAL INTACT: <br /> Samples) Cosier y No(Not Intact)- Not Ap lxable(NIA): <br /> lnitl'at• . <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of-Custody document(s)recehred with samples ........ / ... ... <br /> �Sampie oontiin rr label(s)consistent with custody papers . . . ..,.... <br /> Sample contalner(s)Intact and good condition .. . i .... <br /> Correct oontainers Tor analyses requested . / .. <br /> Proper preservation noted on sample label(s) .. . �. i .. .. _ . .... <br /> VOA vial(s)tree of headepace . , . , ... <br /> Tedlar bags)free or condensation „, ._ _ ,. l <br /> In�ial- <br /> COMMENTS: <br /> \/Cr4 V 14S 63--01 =Zf(. ecce. YWef- <br /> i <br />