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r <br /> Page 14 of 14 <br /> AIni ' WORK ORDER #: 08 - 0- F © � 0 <br /> Cooler t of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: CoDATE: r' <br /> Z9 01f <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. 'C IR thermometer. <br /> Chilled and placed in cooler with wet ice. Ambient temperature. <br /> Ambient and placed in cooler with wet ice. <br /> r <br /> Ambient temperature. <br /> °C Temperature blank. Initial: <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No (Not Intact) : Not Present: <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> low Chain-Of-Custody document(s)received with samples......................... y" ... .... <br /> Sampler's name indicated on COC................................................. ✓ ... .... <br /> Sample container label(s)consistent with custody papers..................... '✓ ... ... . <br /> r Sample container(s)intact and good'condition................................... . ... ... . <br /> Correct containers and volume for analyses requested....................... \/- ... ... . ... ... . <br /> Proper preservation noted on sample labels . i/- ... .... <br /> VOA vial(s)free of headspace. ....................................................... ✓ ... ... . <br /> Ted lar bag(s)free of condensation................................................... . ... ... . ... .... <br /> r <br /> Initial: <br /> COMMENTS: <br /> Y-1 <br /> V <br /> �1 <br />