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Rn� <br /> vrr�rr�n�rs � WORK ORDER M 02-� <br /> ab�r���sfsa, itr�. <br /> Cooler I of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: A4r DATE: <br /> =TEMPERATURE=SAMPL S=RECEIVED-BY: <br /> CALSMENCE COURIER; • LABORATORY (Other than Calacience Courier): <br /> Choles.cooler with temperature blank provided 'C Temperature blank. <br /> Chilled,cooler without temperature blank. 'C IR thermometer. <br /> Chilies!and placed in cooler with wet me Ambient temperature <br /> Ambient and placed in cooler wtfh wet tee <br /> Ambient temperature. <br /> °C Tempermture blank. InNal.4L_ <br /> CUSTODY SEAL INTACT: <br /> Sample(s). Cooler No(Not Intact) . _ Not Applicable(NIA) <br /> Initial* <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Ofo,Custody documegt(s)rived with samples <br /> -- - TSampla contamer_label(s)consistent with custody papers <br /> Sample contalner(s)Infarct and good condition. <br /> Correct containers for analyses requested <br /> Proper preservation noted on sample label(s)....... ►� .. .. .... <br /> VOA vial(a)Uee of headepace <br /> Tedlar bag(s)free of wdensation . , ... �....... �/ <br /> lnfti�l= <br /> COMMENTS: <br />