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WORK ORDER M ©© - 111 FIL - ©®�© <br /> �ebareta�rte� Irtc,. <br /> Cooler �I- of I— <br /> SAMPLE RECEIPT FORM <br /> CLIENT: 41.1 - DATE: <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. O 'C Temperature blank. <br /> Chilled, cooler without temperature blank. OC 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 (N/A): <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-Of-Custody document(s) received with samples......................... _--- ----- <br /> Sample <br /> .. ....Sample container label(s)consistent with custody papers..................... ....... <br /> Sample container(s) intact and good condition................................... j/ ... .... <br /> Correct containers for analyses requested......................................... I/... .... ... .... <br /> Proper preservation noted on sample label(s)..................................... _ <br /> VOA vial(s)free of headspace. ....................................................... ... ... . ... ...._ - <br /> Tedlar bag(s)free of condensation................................................... ....... <br /> t Initial: <br /> COMMENTS: <br />