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Page 28 of 28 <br /> r8=bcw=tU"c1fff*M0Ww6i�, WORK ORDER #: O6 - - aoao Inc. I r of <br /> Cooe / .�_ <br /> SAMPLE RECEIPT FORM <br /> CLIENT: c DATE: % <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. 'C Temperature blank. <br /> Chilled, cooler without temperature blank. _�. OC 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 (N/A).- <br /> Initial: <br /> N/A):Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-Of-Custody document(s) received with samples......................... / ••• ••• <br /> Sampler's name indicated on COC................................................. / ... ... . ... ... . <br /> Sample container label(s) consistent with custody papers..................... � h <br /> Sample container(s) intact and good condition................................... �_••. ••• • •.. <br /> Correct containers and volume for analyses requested....................... / <br /> Proper preservation noted on sample label(s)..................................... ... ... . ... ... . <br /> VOA vial(s) free of headspace. ....................................................... ... •.. . ... ... .�i <br /> Tedlar bag(s) free of condensation................................................... ... ... . ... .... I--- <br /> Initial:4?_9 <br /> COMMENTS: <br /> — <br /> �ff <br />