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T ----- F14 ate+ r,aU j r Inti/ITj <br /> IMM6 WORK ORDER,#: 02Z] [9 - M @ [B ff] <br /> i Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE: <br /> TEMPERATURE--SAMPLL3 RECEIVED BY: <br /> —..Lf I <br /> CALSCIENCE COURIER: L.AWRATORY(car than Calsvrenca Gotioer): <br /> Chilled,cuc4er"Ath temperaturs blank prmAded. -- - °C TempeMtura blghk. <br /> ChOled, cler without tempore blank .,... *C IR therwrr aW. <br /> Chilled and phmW In cooler with wet ice. Amb-ent temperature. <br /> Ambient and placed In chalet with wet ice. <br /> AmWnt temperature. <br /> ,.. _ <br /> 'C Temperate re bighk. <br /> Initial . <br /> CUSTODY SEAL fNTACT: <br /> sernple(s)-,. Cnde r� No(Not Into• Not A cable(INVA): <br /> ply 4 A)•�.�...� <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No r NIA <br /> Chain•Of-Custody documents) remind with samples. ..... .. <br /> Sample container label(s)coni;W&A with cushy papors -- - . Ir <br /> ....... ....... <br /> Sample contatner(s)kjW and#fid condition.....,.... _ _ .... .... 1l ... <br /> Correct contalners for armiyum requested ............. .. ..... . ............. <br /> Proper preservation noted an sample tabu(a)........ ...... ....... •. ., <br /> VOA%mil(s)free vt headsptrca ..,.... . ......... . .......... .... ....... .... Z/ <br /> Tedlor begs)tree of -�•.,.,,. ` <br /> ccxl+�ensat€aon . ... ...... ......, .,...... ....F,.. .... .... <br /> nrtial; <br /> F <br /> MMENTS: <br />