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irk lerrcg , <br /> raboratories. <br /> WORK ORDER #: O2-❑ E - � M [0 E Inc. <br /> s <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: elF- �W1CK ,17'icA,— I LLt' I DATE' 5/0 ' <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER LABORATORY (Other than Calscience Courter) <br /> Chilled, cooler with temperature blank provided °C Temperature blank <br /> Chilled, cooler without temperature blank °C IR thermometer <br /> i <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 (NIA) <br /> Initial <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 l <br /> Sample container(s) intact and good condition <br /> Correct containers for analyses requested <br /> Proper preservation noted on sample label(s) <br /> VOA vials)free of headspace <br /> Tedlar bag(s)free of condensation , <br /> Initial <br /> COMMENTS: <br />