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WORK ORDER #: ©© - mm- <br /> Cooler <br /> �� of <br /> SAMPLE RECEIPT FORM <br /> CLIENT t.r DATE. S L� <br /> TEMPERATURE—SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER. LABORATORY (Other than Calscience Courter): <br /> Chilled,cooler with temperature blank provided 'C Temperature stank <br /> Chitled,cooler without temperature blank 7— °C IR thermometer <br /> Chilled and placed in cooler with wet Ice Ambient temperature <br /> Ambient and placed in cooler with twat ice <br /> Ambient temperature <br /> aC Temperature blank Instyal <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler No fNot Intact) Not Applicable(NIA) <br /> SAMPLE CONDITION* <br /> Yes No NIA <br /> Cham-Of-Custody document(s) received+mth samples = <br /> Sample container tahel(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 _ <br /> Initial <br /> COMMENTS: <br />