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AEW <br /> � WORK ORDER #: 04 <br /> tifl — L?I n LJ <br /> Inc. <br /> Cooler of �1 <br /> SAMPLE RECEIPT FORM <br /> CLIENT:— DATE: h/20M <br /> TEMPERATURE— SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY(Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. T °C Temperature blank. <br /> Chilled, cooler without temperature blank. 1 ' '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 documents) received with samples......................:.. ... .... ... .... <br /> Sample container label(s)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 />