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I <br /> 4�1SG,enC� - <br /> nvrros�rnerrral WORK ORDERF1 <br /> Cooler <br /> Areboratorles. Inc. <br /> Cooler _� of <br /> SAMPLE RECEIPT FORM <br /> CLIENT._ FG101 l <br /> -- ._ DATE; I d rr�� l <br /> TEMPERATURE -- SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY(Other than Caisdence Courier): <br /> Chilled, cooler with temperature blank provided "C Temperature blank <br /> Chilled, cooler without temperature blank °��C IR thermometer <br /> Chilled and placed m I✓Amcooler with wet ice bient temperature <br /> Ambient and placed in cooler with wet Ice <br /> Ambient temperature <br /> °C Temperature blank, Ing ial <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler No (Not Intact) Not Applicable(NIA) <br /> It Initial <br /> 41 SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of-Custody document(s)received with samples <br /> Sample container label(s)consistent w►th 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 /> Tealar bag(s)tree of condensation ✓ <br /> Initial <br /> COMMENTS: <br /> TOTAL P 15 <br />