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rl0rir�idrrl�l <br /> W0RK ®RDER #: 03-® 0 0 H a [fl 0 , <br /> Cooler - j _ of <br /> SAMPLE RECEIPT FORM <br /> CLIENT:--k4, DATE: <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER- LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided �� '3C 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 /> Initial <br /> SAMPLE CONDITION: <br /> Yes <br /> Na NIA <br /> Chain-Of-Custody document{s} received with samples <br /> ^r� <br /> Sample container label(s)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 <br /> Tedlar bag(s) free of condensation <br /> Initial <br /> COMMENTS: <br />