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surras <br /> � ��•,' ' WORK ORDER #: 02-E R - U] Efl 0 !.J <br /> si�►r�ecsrtsa, � <br /> Cooler . r of i <br /> SAMPLE RECEIPT FORM <br /> ` <br /> CLIENT: DATE;_ 1125LOL <br /> TEMPE =SAMPL S-RECEIVED=BY: <br /> CALSCIENCE COURIER: • LABORATORY 10ther than Calaeionee Courier): <br /> Chilled, cooler with temperature bW*provided _�^, °C Temperature blank. <br /> Chilled, cooler without temperature blank. �°C lR thermometer. <br /> Chilled and placed in 000ler with wet ke Ambient temperature <br /> Amblent and placed .n cooler with wet Icer. <br /> Amblent temperatum <br /> °C Temperature blank. Initial.4f- <br /> CUSrODY <br /> SEAL INTACT: <br /> Sample(s). Cooler. No(Not last) _ Not Applicable(PUA): <br /> InitiaL <br /> .p <br /> SAMPLE CONDITION: " <br /> tel., /�t•. y,�� rt _,,,�J-.,,i` Y}esJ No , NIA <br /> Cheln-Ot-Custody docum mqi)received with samples. . i/ r r. �.►s ... <br /> Sample contane-r latent with-custody-papers-a ) ons <br /> - .....:..,.... ... ... _M__.r.— <br /> Sample container(s)Intact and good condition.. ... ... <br /> Correct contalnere for armlyses requested . <br /> Proper preservation noted on sample label(s)....... ...... . . . _ 1! ,. ... ... <br /> VOA vial(a)free of headopace . . -- - . . .. . - - - .. . <br /> Tedlar bag(s)free of condensation . . ... .. . .. ........ .. . 1/ <br /> Inww: <br /> COMMENTS: <br />