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WORK ORDER #: 04- <br /> Cooler <br /> 04 -Cooler 1 of <br /> SAMPLE RECEIPT FORM <br /> r <br /> CLIENT: k l � r DATE: 1f 23 [ D <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 /> Chain-Of-Custody document(3) received with samples...................... <br /> Sample container label(s) consistent with custody papers..................... <br /> Sample container(s) intact and good condition................................... I\.,- <br /> Correct containers for analyses requested............... ,,/ ... ... . ... ... <br /> Proper preservation noted on sample label(s)........... <br /> VOA vials)free of headspace. ............ <br /> ., ... <br /> Tedlar bag(s)free of condensationr .. ...................................... <br /> Initial. <br /> COMMENTS: <br />