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ctanaa <br /> v ��.�� � C� D a <br /> or�etorlea. ono. WORK ORDER #: 02- • <br /> Cooler � of <br /> SAMPLE RECEIPT FORM <br /> CLIENT; DATE: O ... <br /> TEMPERATURE -.SAMPL S RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY(Other than Calealenoe Courier): <br /> Chilled, cooler with temperature blank provided °C Temperature blank. <br /> Chilled, cooler without tsmperature blank °C IR thermometer <br /> Chilled and placed In cooler with wet ice Ambient temperature <br /> Ambient and pieced in cooler with wet ice, , <br /> • _�Ambient temperature <br /> C Temperature blank, Inwal. <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler <br /> No(Not Intact) Not Applicable(N/A)- <br /> Initial, <br /> S <br /> AMPLE CONDITION: <br /> :ria+n-Of-Custody documents)received vAth samples Yes No WA <br /> CC <br /> Sample container label(s)consistent with custody papers . , 'V .. <br /> Sample contaitter(s)intact and good condrdon V , <br /> Correct containers for ana"es requested "�- <br /> Proper preservation noted on sample label(s) „ <br /> VOA vials) tree of headspace . v <br /> TOW bag(s)free of condensation .. .. . . ,y <br /> Initial: <br /> ff <br /> COMMENTS: <br /> TOTAL P.e7 <br />