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MRR-13-20W 11 45 CFxLSC I ENCE ENV I W NTAL 714 894 7501 P.05/06 <br /> isit <br /> E, =-. WORK ORDER #: 03.[a ® o WN [E ng <br /> cooler � of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: Mi DATE: 31 3 <br /> TEMPERATURE --SAMPLES RECEIVED.BY: <br /> CALSCIENCE COURIER: LABORATORY(Other than Calsolence Courier): <br /> Chilled,cooler with tsmileratete blank provided _ °C Temperature blank <br /> Chilled, cooler without temperature blank °C IR thermometer <br /> Chilled and placed In 000ier with wet ice Ambient temperature <br /> Ambient and placed in cooler with wet ice <br /> Ambient temperature. <br /> °C Ternparaturo blank. Initial <br /> CUSTODY SEAQ.INTACT: <br /> Samples) CoolerNo(Not Intact) Not Applicable (N/A). <br /> Ingle, <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Cham-Of-Custody document(&)received with samples r .. ...... <br /> Sample container label(s)consistent with custody papers . <br /> Sample container(s)intact and good conddlon r .... . <br /> Correct containers for enalyaes requested / .. �" <br /> Proper preservation noted on sample Inbei(s) <br /> VOA vial(s)free of headspace, .. <br /> T'edlar bag(s)free of condensation, <br /> Initial: � <br /> COMMENTS: <br />