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r.. <br /> WORK ORDER #: 03 -Fe fl - ©®r© <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT:-94—kr— 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: T�I <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No(Not Intact): Not Applicable(N/A): <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes NoN/A <br /> Chain-Of-Custody document(s) received with samples........................ ... ..... �� <br /> Sample container label(s)consistent with custody papers..................... _1l ....... <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................................................... ... .... ......._ l/ <br /> Initial: <br /> COMMENTS: <br />