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Page 10 of 10 <br />- nn <br />WORK ORDER #:08 - D ❑3 - L� Z❑ <br />kAbamfoides. Pam Cooler of <br />A/ rrSSAMPLE RECEIPT FORM <br />ri IFNT• WeO' ev'n l: f?�Q�t/r'iD T, l' nerF• ��a6�ae <br />TEMPERATURE — SAMPLES RECEIVED BY: <br />CALSCIENCE COURIER: <br />Chilled, cooler with temperature blank provided. <br />Chilled, cooler without temperature blank. <br />Chilled and placed in cooler with wet ice. <br />Ambient and placed in cooler with wet ice. <br />Ambient temperature. <br />'C Temperature blank. <br />LABORATORY (Other than Caliscience Courier): <br />'C Temperature blank. <br />TS 'C IR thermometer. <br />Ambient temperature. <br />Initial: �, L– <br />CUSTODY SEAL INTACT: <br />V <br />Sample(s): Cooler: No (Not Intact) : Not Present: <br />Initial: N L, <br />SAMPLE CONDITION: <br />Chain -Of -Custody document(s) received with samples .........................V....... <br />Sampler's name indicated on COC ................................................. <br />Sample container label(s) consistent with custody papers ..................... <br />Sample container(s) intact and good condition ................................... <br />Correct containers and volume for analyses requested ....................... <br />Proper preservation noted on sample label(s)..................................... <br />VOA vial(s) free of headspace........................................................ <br />Tedlar bag(s) free of condensation................................................... <br />Yes <br />....... <br />�....... <br />....... <br />....... <br />....... <br />No N/A <br />....... <br />....... V <br />....... <br />.......7— <br />Initial: " <br />COMMENTS: <br />