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Mw-26-2003 17:13 P.11112 <br /> WO RK ORDER#: 036 girkdorhPOS hUP6 <br /> Cooler Of <br /> SAMPLE RECEIPT FORM <br /> ti <br /> cLlWENT: DA : C-11a 103 <br /> � TE <br /> WERATURE—SAIIAPLES REC iVED BY: <br /> TE <br /> CALSCIENCE COURIER: LABORATORY(Other than Calsclence Courier): <br /> Chided, cooler with temperature blank provided. °C Temperature blank <br /> Chilled, cooler wuwut temperature blank. °C IR thermometer. <br /> ChWed and placed in cooler with Wet ice. Ambient temperature. <br /> Ambient and plaoed in cooler with wet ice <br /> Ambient temperature. <br /> C Temperature blank. Initial: <br /> CUSTODY SEAL INTACT: <br /> gaEnpLs(e): Cooler:-2— No(Not Intact): Not A.pplicablit(N/A): <br /> InMW: �+ <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-Of-Custody document(s) with samples. ....................... ... ..,. ..... �...� <br />�sampWconuoorilabel(s)-coneiatsnt°wlth,cUstodY-'papere ................. <br /> �_� ,:.,:...:.. .••:•:•:•.• .—�-� <br /> Sample container(s)Intact and goad condition................................... _ ... .... ....... <br /> Comectcontainers far analyses requested......................................... ,_ .., .... .......--- -—. <br /> Proper pieservatlon noted on Sample label(s)..................................... ... .... ....... <br /> VOAvial(a)fn*e of headepece. ................................. .................... ... ... .... <br /> Tedlar bag(s)fine of condensation................................................... ... .... .......�..�r�.. <br /> Inlfial:�G <br /> COMMENTS: <br />