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WOf 1.` RDERA 0 -Ul [9 — U] [D iii M <br /> of <br /> SAMPLE RECEIPT FORM <br /> CIJ9NT: DATE: Z �� <br /> =TEMPERATURE---SAMPLLWRECEIVED BY: <br /> CALSCIENCE COURIER_ LABORATORY(Other than Ca#sr;Ience Coiner): <br /> Chiled,cooler w h ten 1perators bunk pmvided. rw °C TCmpW hn blfhk. <br /> Cmftf, Cooler whhout IRMPffwm* 60111 themnam�er. <br /> - ChBled and placard in coWw with wet kw Ambient*nVwawm. <br /> Ambient and phmed to conlet with wet ktie <br /> AmbWa tamperubm <br /> C TernwMrrre blhltk• Midas <br /> CUSTODY SEAL INTACT: <br /> sam�te(s). Cooler: No l <br /> �. {Not ntacq'� Not Applicable(WA): <br /> Inmt <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of- ush*documents)remNed wwtthh strmples ...... ............ .. ....,-- <br /> container consts�t with -� ----• �"--,� <br /> — �3arnpie la>��s) PaA�- ----- -•--......:. <br /> Sample cantahner(s)MW arrd good wndlt om......... . .. . ........ ....... 1l _.... <br /> Correct contsirmm far analyses requested...................................... . ..... <br /> NOW Pmewintlon noted on sample 1pW(a)................... .......... ......�,,.._._....... .... <br /> VDA vias($)tree of he oe. % • , -', <br /> 7edW beg(s) r../V{r1 COMWMUN................. <br /> ...........u... .••...H.as..•.w�.w...��i....••��..t s.s a <br /> Initial: <br /> COMMENTS: <br />