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lT�Y <br /> � t r, WORK ORDER #: 04 - <br /> Cooler of I • <br /> SAMPLE RECEIPT FORM <br /> CLIENT: I DATE. D <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER- LABORATORY (Other than Caiscience Courier) <br /> Chilled, cooler with temperature blank provided 44 *C Temperature blank <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 �- <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler i No (Not Intact) Not Applicable (NIA) <br /> Initial <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of-Custody document(s) received with samples IJ, <br /> Sample container label(s)consistent with custody papers <br /> Sample container(s)intact and good condition <br /> Correct containers 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 �L/ <br /> Initial <br /> COMMENTS: <br />