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/asrca - (J <br /> WORK ORDER DER #: Q4 -0© - �® <br /> reboratories. Inc. <br /> Cooler �_ of <br /> SAMPLE RECEIPT FORM <br /> CLIENT•__ Lt _ DATE: > <br /> TEMPERATURE - SAMPLES RECEIVED BY' <br /> LABORATORY (Other than Calscience Couper) <br /> CALSCIENCE COURIER <br /> Chilled, cooler with temperature blank provided �-? <br /> °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 /> ' <br /> F <br /> SEAL INTACT: <br /> Cooler�� No(Not Intact) Not Applicable (N/A) <br /> Initial <br /> SAMPLE CONDITION- Yes No NIA <br /> Chian-Of-Custody document(s)received with samples /- <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 /> 1 Tedlar bag(s)free of condensation --- <br /> Initial <br /> FCMOMMENTS' <br /> rdw r2 to <br />