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Page 18 of 18 <br /> WORK ORDER #: 05 - F21 © - [j] F21 9 <br /> Cooler t of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: VArIF DATE: <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calsclence Courier): <br /> Chilled, cooler with temperature blank provided `J -4k— 'C 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(NIA) ,2 <br /> Initial <br /> SAMPLE CONDITION: <br /> Yes No NIA <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 <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 />