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Page 7 of 7 <br /> Olen ce <br /> �► v3ranmeeafaf ' <br /> �.etacr- tarts. r., _ WORK ORDER #: 05 <br /> v 5 Cooler of`�_ e <br /> SAMPLE RECEIPT FORM <br /> CLIENT-- 1 L-"thn4'� DATE <br /> TEMPERATURE — SAMPLES RECEIVED BY. <br /> CALSCIENCE COURIER LABORATORY (Other than Calscience Courier) <br /> Chilled,cooler with temperature bfank'provided °C Temperature blank w }- <br /> Chilled cooler without temperature blank °C IR thermometer <br /> Chilled and placed in cooler with wet ice Ambient temperature <br /> Ambient and placed in cooler with wet ice <br /> Ambient temperature <br /> °C Temperature blank Initial 'V <br /> CUSTODY SEAL INTACT <br /> Sample(s) Cooler 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 Iabel(s)consistent with custody papers <br /> Sample containers) ntact and good condition <br /> Correct containers for analyses requested <br /> -Proper p�eservatron noted an sample label(s) <br /> VOA vial(s)free bf headspace <br /> Tediar bag(s)free of condensation <br /> Initial <br /> COMMENTS: <br />