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Page 24 of 24 <br /> WORK ORDER #: 0 - © a - E 0 a <br /> Cooler \ of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: �l4`p�0�1S 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. 4 . `Z-°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: <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No (Not Intact) : Not Present: <br /> Initial: W J <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)..................................... . . ... ... " 1�--- <br /> VOA vial(s)free of headspace. ....................................................... ... ... . <br /> Tedlar bag(s)free of condensation................................................... ... ... . <br /> Initial: <br /> COMMENTS: <br />