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(ii larr��r <br /> WORK ORDER #: 03-[d ® - [j] [�j El 0 <br /> l atoratarlask Ina. <br /> - Cooler _ l of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: k` DATE: 3 <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier). <br /> Chilled, cooler with temperature blank provided 3 °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 /> OC 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 /> Cham-Of-Custody document(s) received with samples <br /> Sample container label(s) consistent with custody papers <br /> Sample container(s) intact and good condition _V <br /> Correct containers for analyses requested � -,rl-_ <br /> proper preservation noted on sample label(s) �Z <br /> VOA vial(s) free of headspace ✓ <br /> Tedlar bag(s) free of condensation t� <br /> Initial s <br /> COMMENTS: <br />