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WORK ORDER #: 04.-DID - [MIRM <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: t ! GATE: /112� /0 <br /> FCALSCIENCE <br /> RATURE— SAMPLES RECEIVED BY: <br /> 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 <br /> nitial:CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: `�./ No(Not Intact) : Not Applicable(NIA): <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-0f-Custody document(s)received with samples................... <br /> Sample container label(s) consistent with custody papers..................... U ... .... <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 headspape. .......................................... <br /> � <br /> Tedlar bag(s)free of condensation,,,,,, <br /> Initial: <br /> COMMENTS: <br />