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Page 69 of 79 <br /> ift W, W ,_ WORK ORDER #: 08 in - ® ® - ® © ❑� G❑ <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE:. <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. _3 . K°C Temperature blank. <br /> Chilled, cooler without temperature blank. °C IR thermometer. <br /> Chilled and placed in cooler with wet ice. Ambient temperature (For Air& Filter only). <br /> Ambient and placed in cooler with wet ice. <br /> Ambient temperature(For Air& Filter only). <br /> 'C Temperature blank. Initial:—T....... <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No (Not Intact) : Not Present: <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-Of-Custody document(s) received with samples......................... V- ... ... . <br /> Sampler's name indicated on COC................................................. ,/- ... ... . ... ... . <br /> Sample container label(s) consistent with custody papers..................... ✓ ... ... . <br /> Sample container(s) intact and good condition................................... ✓ ... ... . <br /> Correct containers and volume for analyses requested....................... ... ... . ... ... . <br /> Proper preservation noted on sample label(s)..................................... X/, ... ... . ... ... . <br /> VOA vial(s)free of headspace. ....................................................... X/1- .. . ... ... . <br /> Tedlar bag(s)free of condensation................................................... ... ... . ... ... .lz <br /> Initial: <br /> COMMENTS: <br />