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nn <br /> WORK ORDER#: 04 -0® - 0©©L- <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT- \ DATE: 611, <br /> TEMPERATURE--SAMPLES RECEIVED BY: <br /> CA!!SCIENCE COURIER. LABORATORY(Other than Calsclence Courter): <br /> Chilled, cooler with temperature blank provided `2- G °C Temperature blank <br /> Chllled, cooler without temperature blank °C IR thermometer <br /> Chllled and placed In cooler with wet Ice Ambient temperature <br /> Ambient and placed In cooter with wet ice <br /> Ambient temperature <br /> °C Temperature blank Initial <br /> CUSTODY SEAL INTACT. / <br /> Sample(s) Coolor✓ No(Not Intact) Not Applicable(NIA) <br /> Initial <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of-Custody document(s)received with samples <br /> Sample container label(s) consistent wdh custody papers <br /> Sample conlalner(s) Intact and good condition <br /> Correct containers for analyses requested <br /> Proper preservation noted on sample labei(s) <br /> VOA vial(s)free of headspace _ -T�r <br /> Tedlar bag(s)free of condensation <br /> ,.._ Initial <br /> COMMENTS, <br /> � i <br />