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Page 8 of 8 <br /> V�isi�ica <br /> Hbaz'atorl s WORK ORDER #: 05 - �� uj <br /> 10 �17ar,��o►�ite�s, Inc- <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: �ty-y DATE: <br /> TEMPERATURE --- SAMPLES RECEIVED R:`: <br /> CALSCIENCE COURIER: LABORATORY (Other than Ca[science Courier): <br /> Chilled, cooler with temperature blank provided. °C Temperature blank- <br /> Chilled, cooler without temperature blank. 2"S _ 'C 1R 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:TL- -- <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No(Not Intact): Not Applicable (NIA): <br /> Initial:T'-�- <br /> SAMPLE CONDITION: <br /> Ye No NIA <br /> Chain-Of-Custody document(s)received with samples......................... ... ... . ... ... . <br /> Sample container label(s) consistent with custody papers..................... <br /> . ... . <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: l V <br /> COMMENTS: <br />