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- WORK ORDER #: 04 <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE: <br /> FCTEMPERATURE <br /> — SAMPLES RECEIVED BY: <br /> ALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. °C Temperature blank. <br /> Chilled, cooler without temperature blank. OC'!— °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 ApplicableN/A : <br /> c ) <br /> Initial: <br /> SAMPLE CONDITION: <br /> Ye No NIA <br /> Chain-Of-Custody document(s) received with samples......................:.. 7 .,_ ._, <br /> ... .... <br /> Sample container labels) consistent with custody papers..................... ... ... . <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. ....................................................... . .... ... ... . <br /> Tedlar bag(s)free of condensation................................................... <br /> Initial: <br /> COMMENTS: <br />