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1 <br /> Ak== <br /> WORK ORDER M 04 <br />' Cooler „�„• i of I <br /> SAMPLE RECEIPT FORM <br /> CLIENT: l4l DATE: >d7 $ <br />' TEMPERATURE —SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY(Other than Calscience Courier): <br />' Chilled,cooler with tem perature blank provided `gl=+ °C Temperature blank <br /> Chilled,cooler without temperature blank. °C IR thermometer <br /> Chilled and placed In cooler with wet ice Ambient temperature <br /> Amblent and placed In cooler with wet ice <br /> Ambient temperature <br />' °C Temperature blank Initial "'�1.✓ - <br />' CUSTODY SEAL INTACT: <br /> Sample(s) Cooler No(Not Intact) Not Applicable(NIA) <br /> Initial <br /> SAMPLE CONDITION: <br /> Yes No NIA <br />' Chain-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 vlal(s)free of headspace ; <br /> Tedlar bag(s)free of condensation <br /> Initial 7(y <br /> 1 <br /> COMMENTS: <br /> 1 <br /> 1 <br /> 1 <br />