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WORK ORDER #: 04 -- <br /> Cooler <br /> 4 --Cooler of <br /> SAMPLE RECEIPT FORM <br />' CLIENT: ANAL TI'LA , DATE: s <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br />' CALSCIENCE COURIER: LABORATORY (Other than Calsclence 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 />' Ambient temperature <br /> °C Temperature blank Initial _ N <br />' CUSTODY SEAL INTACT: <br /> Sample(s)les) Cooler r ✓ No(Not Intact) Not Applicable(NIA) <br />' Initial �- <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Cham-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 <br /> Initial [�`r <br />' COMMENTS: <br />' T <br />