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Page 9 of 9 <br /> 1404 <br /> = WORK ORDERM a o a a a <br /> Cooler / of l <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE: <br /> TEMPERATURE- SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. S_ °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: <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No(Not Intact) : Not Applicable(N/A): <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-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.................................................. ... V/ <br /> Initial: <br /> 1� <br /> COMMENTS: <br />