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Page 18 of 18 <br /> WORK ORDER#: 06 - ® � - © © Q <br /> Cooler I of I <br /> SAMPLE RECEIPT FORM <br /> CLIENT:- B10131 h.P. tCJ1 S1f4�_ DATE: <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 i2. °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 tIJ C. <br /> CUSTODY SEAL INTACT: <br /> Samples) Cooler No(Not Intact) Not Applicable (NIA) <br /> Initial L <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of-Custody document(s)received with samples _... . <br /> Sampler's name indicated on COC <br /> Sample container label(s)consistent with custody papers _1z ... <br /> Sample container(s) intact and good condition .— <br /> Correct containers and volume for analyses requested ... .... <br /> Proper preservation noted on sample labet(s) .. <br /> VOA vial(s)free of headspace .. <br /> Tedlar bag(s)free of condensation _ <br /> Initial rG <br /> COMMENTS: <br />