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Page 12 of 12 <br /> x7 - WORK ORDER #: Q5 - FI) R <br /> ❑ L� <br /> Coolerf . <br /> o . _ <br /> SAMPLE RECEIPT FORM <br /> CLIENT: % �A1.^�C�CA.ti DATE: eb -2c 05 <br /> TEMPERATURE — SAMPLES RECEIVED BY. <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier) <br /> Chilled, cooler with temperature blank provided <br /> °C Tern perafure blank <br /> Chilled, cooler without temperature blank <br /> °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 /> 0 C Temperature blank f ,1 <br /> Initial W <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler No(Not Intact) Not Applicable(NIA) <br /> Initial W`5 . <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 <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 <br /> Initial <br /> COMMENTS. <br />