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Page 15 of 15 <br /> ❑ ❑ ❑ ❑ ❑ a <br /> AI+rilI WORK ORDER #: OC - d �` - <br /> b VPfV0. Imo. <br /> Cooler of. <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE: /,C <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. 5 °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:. <br /> CUSTODY SEAL INTACT: <br /> y Sample(s): Cooler: (Not Intact): Not Applicable(N/A): <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> 7' Chain-Of-Custody document(s)received with samples........................._�... .... ... .... <br /> Sampler's name indicated on COC................................................. / ... .... <br /> Sample container labels)consistent with custody papers..................... ....... ... .... <br /> Sample container(s)intact and good condition................................... �_:.. .... ... .... <br /> Correct containers and volume for analyses requested....................... ... .... <br /> Proper preservation noted on sample label(s).....................................r��... .... ... .... <br /> VOA vial(s)free of headspace. ........................................................ / . <br /> Tedlar bag(s)free of condensation................................................... ... .... ... ... <br /> Initial: <br /> COMMENTS: <br />