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�R� ORDER #: 03-� El a Q El FLI <br /> M <br /> Cooter of - r -- <br /> SAMPLE RECEIPT FORM + <br /> CLIENT: DATE: <br /> - IA 1/0-z' <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Caiscience Courier): <br /> Chilled, cooler with temperature blank provided ` °C Temperature blank <br /> Chilled, cooler without temperature blank °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 /> 0 Initial <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-Of-Custody document(s) received with samples <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 /r <br /> Tedlar bag(s) free of condensation _ <br /> Initial <br /> COMMENTS: <br />