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MRR-03-2003 10 27 CALSCIENCE ENVIRONMENTAL 714 B94 7501 P.05 <br /> ~ 1y M . <br /> • t <br /> 0 <br /> �,� WORK ORDER#: � �® M ' <br /> R E 10 <br /> Cooler •�_ of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE: Z <br /> TEMPERAYURE-SAWPLES RECEIVED BY; <br /> CALSCIENCE COURIER: LABORATORY(Other than Cefeclence Courier): <br /> Chilled,cooler with temperature blank providedC 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 ze <br /> Ambient temperature <br /> °C Temperature blank Initial <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler V No (Not Intact) Not Applicable(NIA) <br /> Initial <br /> SAMPLE CONDfTION: <br /> Yes No NIA <br /> Cham-Of-Custody document(s)received with samples V ....... <br /> Sample container label(s)consistent with custody papers �..• .... <br /> Sample container(s)Intact and good condition . . . <br /> Correct containers for analyses requested V - <br /> Proper preservation noted on sample label(s) <br /> VOA vial(e)free of headspa©e �..�.. <br /> Tedlar bag(s)free of condensation •• V <br /> Initial <br /> COMMENTS: <br />