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Page 18 of 18 <br /> WORK ORDER #. 4LD u-J <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT:— LE <br /> DATE:,4q OZ, <br /> TEMPERATURE — SAMPLE-S RECE"VEn rte..•. — <br /> CALSCIENCE COURIER: LABORATORY (Other than Catscience Courier): <br /> Chilled, cooler with temperature blank provided. <br /> °C Temperature bfank- <br /> Chifled, cooler without temperature blank. <br /> °C IR thermometer, <br /> Chilled and placed in cooler with wet ice. <br /> Ambient temperature. <br /> Ambient and placed in cooler with wet ice. <br /> Ambient temperature. <br /> °C Temperature blank. b l� <br /> Initial: <br /> 7CUST07DYSE7ALNTACT:Cooler_ No Not Intact ; <br /> ( ) Not Applicable (NIA): <br /> initial: ` <br /> SAMPLE COK0` T.0#m: <br /> PCC <br /> Yes No N!A <br /> Chain-Of Custody document(s) received with sampfes....... .............. <br /> Sample container labef(s) consistent with custody papers................... <br /> Sample containers)intact and good condition............. <br /> ................... <br /> orrect containers for analyses requested..-... ......... <br /> raper preservation Hated an sample fabel(s).................... . . . .... <br /> VdA via(s) <br /> free of headspace. ...... <br /> ........................ <br /> -.. . <br /> Tedlar bags)free of condensation............... . <br /> ................ <br /> Initial: <br /> COMMENTS: <br />