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Page 12 of 12 <br /> • '� WORK ORDER #: 06 - H E -0 E M DI <br /> Cooler I of <br /> SAMPLE RECEIPT FORM <br /> CLIENT _ e- DATE: __ .311,-7-106 <br /> 0G <br /> TEMPERATURE -SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier) <br /> Chilled, cooler with temperature blank provided °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 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 /> Cham-Of-Custody document(s)received with samples �L- <br /> Sample container label(s)consistent with custody papers Y <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 1/ <br /> Tedlar bag(s)free of condensation Li <br /> Initial <br /> COMMENTS: <br />