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- a <br /> abaraxoMm, WORK ORDER #: 02-[E <br /> Cooler . f of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: FF DATE: IQ$ O <br /> TEMPERATURE—SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY(Other than Calsolence Courier): <br /> Chilled, cooler with temperature blank provided. 3 °C Temperature hank. <br /> Chilled,cooler VvittUM temperature Merit. 00 IR thermometer. <br /> Chilled and placed In cooler with wet Ice. Ambient temperature <br /> Ambient and placed in cooler whiz wet Ice. <br /> Ambient temperature <br /> C Temperature blank. InWat �.. <br /> CUSTODY SEAL INTACT: <br /> Sarnple(s)- Cooler. V1.. No (Not Intact), Not Applicable(NIA): --- <br /> Mal <br /> SAMPLE CONDITION: <br /> Yes No N!A <br /> Chair X-Custody documents)received with samples <br /> ^Sampie�Container labe(s)cortsietent with Custody papers.. . ✓ <br /> Sample container(s)intact and good condition....... <br /> Correct containers for analyses guested............ ...... . . . . <br /> Proper preservation noted on sample label(s) <br /> VOA via(s)free of headepace .. . ,. . <br /> .. <br /> Tedlar bags)free of condensation <br /> Initial. ' <br /> COMMENTS: <br />