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' Page 7 of 7 <br /> WORK ORDER M 05 - Fol ® - a © 19 <br /> tarft% Inc_ <br /> Cooler of <br /> ' SAMPLE RECEIPT FORM <br /> CLIENT: cj'eV 5 DATE: <br /> ' TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> ' Chilled,cooler with temperature blank provided. °C Temperature blank. <br /> Chilled, cooler without temperature blank. 4J- 9' OC IR thermometer. <br /> t Chilled and placed in cooler with wet ice. Ambient temperature. <br /> Ambient and placed in cooler with wet ice. <br /> Ambient temperature. 2 <br /> C Temperature blank. Initial: <br /> ' CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No(Not Intact) : Not Applicable(N/A): / <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <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................................... _L... ...• •• • . <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................................................... ... ... • �2 <br /> ' Initial: 2 <br /> COMMENTS: <br />