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WORK ORDER#: 0�4 -®® - 190EIM <br /> Cooler � _. of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: r--� f:�P AlyA-L,--i iaLA L- DATE: 04 <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 wdhout temperature blank. _2 g °C IR thermometer <br />' Chilled and placed in cooler with wet ice Ambient temperature <br /> Ambient and placed In cooler with wet tee <br />' Ambient temperature <br /> °C Temperature blank Initial <br />' CUSTODY SEAL INTACT: <br /> Sample(s) Cooler v No(No# intact) Not Applicable(NIA) <br /> Initial �lV <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chan-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 ••• __��e / <br /> Initial <br />' COMMENTS: <br /> T <br />