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o ' <br /> rior t WORK ORDER #: 0 3-H H] - Pdl 0 El R] <br /> - - Cooler 1 of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: �l�rF� DATE: / d 3 <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�1' No (Not Intact) Not Applicable (NIA) <br /> Initial <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chace-Of-Custody document(s) received with samples <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 1z <br /> Initial <br /> COMMENTS: <br />