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i-age z4 OT'L4 <br /> WORK ORDER #: 08 .. [�l M- ED a g] N-1 <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. �, —0 C Temperature blank. <br /> Chilled,cooler without temperature blank. �.6°C IR thermometer. <br /> Chilled and placed in cooler with wet Ice. Ambient temperature(For Air$Fitter only). <br /> Ambient and placed In cooler with wet Ice. <br /> Ambient temperature(For Air&Filter only). <br /> C Temperature blank. Initial: (7/j <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler. No(Not Intact): Not Present: ✓� <br /> Initial: <br /> S <br /> AMPLECONDITION: <br /> Yes No NIA <br /> document(s)received with samples........................ .... <br /> pname Indicated on COC................................................. V, <br /> ... .... <br /> Sample container labels)consistent with custody papers..................... *'�/" ... .... <br /> Sample container(s)intact and good condition................................... 'V ....... ....... <br /> Correct containers and volume for analyses requested....................... ... .... ....... <br /> Proper preservation noted on sample label(s)..................................... ....... ....... y <br /> VOA vial(s)free of headspace....................... ... .... 'v' <br /> Tedlar bag(s)free of condensation................................................... ....... ....... �✓ <br /> Initial: <br /> COMMENTS: <br />