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JUN-11--23 14.47 P.05 <br /> WORK ORDER#: 03 -Z® - <br /> Cooler �!� of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE: <br /> [TEMPERATURE--SAMPLES RECEIVED 13Y'.CALOCIENCE COURIER: LABORATORY(Other ftri Cslsclence Courier): <br /> Chilled,cooler with ternpomwre blank provided °C Temperature blank. <br /> Chilled,cooler without tomperature blank °C IR thermometer <br /> Chilled and placed in cooler wlpy wet Iae Ambient temperature <br /> Arnbrent and placed In cooler with wet Ice <br /> Ambient temperWure <br /> °C Temperature blank initial <br /> CUSTODY SEAL. INTACT: <br /> Sampie(s) Cooler. No(Not Intact) NotAppiicable(NIA) <br /> Initial. _ • <br /> FCh8VAX-CUStQdy <br /> CONDITION: <br /> Yes No NIA <br /> docUrnar (s)received with samples ,.....,..... <br /> tainer label(s)oonslstent with custody papers <br /> . <br /> Sample container(s)Intoot and good condition -- - .. ... ...... <br /> Cornett con`dinam for anslyses rsqueMd . <br /> Proper preservation noted on sample label(s) <br /> VOA vial(s)fine of heedspace. . .. ... .......... ... .. ....... <br /> Tedlar bag(s)flee of owWansatlon .. ........... .. .. .. .. . . �� <br /> " InitLal -r4- <br /> COMMENTS: <br />