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cfrrto� . <br /> sborscorie�y �. <br /> WORK ORDER #: 04 - a® _ Daae <br /> 1 Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT. DATE: +�� <br /> TEMPERATURE — SAMPLES RECEIVED BY. <br /> CALSCIENCE COURIER: LABORATORY(Other than Calscience Courier). <br /> Chilled, cooler with temperature blank provided 4,7— OC 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 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 with custody papers <br /> Sample container(s)intact and good condition d/ . <br /> Correct containers for analyses requested ~� <br /> ' Proper preservation noted on sample label(s) r <br /> VOA vial(s)free of headspace <br /> Tedlar bag(s)free of condensation <br /> ' Initial <br /> COMMENTS. <br /> t <br />