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Cella�r�nca <br /> ator <br /> W>< r baratorlea. Inc- WORK ORDER #: 05 - 0 FLI - H El a a <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENTDATE: 2 ' 4 r b� <br /> TEMPERATURE -- SAMPLES RECEIVED BY- <br /> CALSCIENCE COURIER LABORATORY (Other than Calscience Courier) <br /> Chilled, cooler with temperature blank provided 3 g °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 IJJ�J <br /> CUSTODY SEAL INTACT: <br /> Sample(s) Cooler / No(Not Intact) Not Applicable(NIA) <br /> Initial <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Cham-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 />