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F <br /> Page 82 of 82 <br /> WORK ORDER #: 08 <br /> _ + JAIM <br /> Cooler k of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: VA -e o > 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. _ 3 °C IR thermometer. <br /> Chilled and placed in cooler with wet ice. Ambient temperature (For Air & Filter only). <br /> Ambient and placed in cooler with wet ice. <br /> Ambient temperature (For Air& Filter only). <br /> _ °C Temperature blank. Initial: Wl(!7 <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No (Not Intact) : Not Present: / <br /> 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..................... <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. ....................................................... ... ... . <br /> Tedlar bag(s)free of condensation................................................... ... ... . ... ... . ' e/ <br /> Initial: Wy� <br /> COMMENTS: <br />