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Page 7 of 7 <br /> WORK ORDER #: 05 - Ul ® - 1 LIJ ® a <br /> Cooler l of <br /> SAMPLE RECEIPT FORM <br /> CLIENT:--Ll Aa <br /> 41 vDATE:_ 7/ 3 <br /> TEMPERATURE -- SAMPLES RECEIVED BY: <br /> CALSCiENCE COURIER. LABORATORY (Other than Calscience Courier) <br /> Chilled, cooler with temperature blank provided '2. °C Temperature blank <br /> Chilled,cooler without temperature blank '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 /> °C Tern perature blank Initial <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler No(Not Intact) Not Applicable (NIA) <br /> Initial <br /> SAMPLE CONDITION: <br /> l No NIA <br /> Chain-Of-Custody document(s) received with samples Yep, <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 labef(s) — <br /> VOA vial(s)free of headspace <br /> Tedlar bag(s)free of condensation <br /> Initial <br /> COMMENTS, <br />