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Page 8 of 8 <br /> WORK ORDER #: 055 - 10 <br /> Cooler . of <br /> SAMPLE RECEIPT FORM <br /> CLIENT y-`N--� DATE: <br /> TEMPERATURE -- SAMPLES RECEIVED BY. <br /> CALSCIENCE COURIER LABORATORY (Other than Calscience Courier) <br /> Chilled, cooler with temperature blank provided 3.2 OC 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 (N/A) <br /> . Initial <br /> SAMPLE CONDITION <br /> Yes No N/A <br /> Chain-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 f <br /> Proper preservation noted on sample labels) — — <br /> VOA vial(s)free of headspace <br /> Tedlar bag(s)free of condensation <br /> Initial <br /> COMMENTS. <br />