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l�rt�aa <br /> ��rortnr> a1 WORK ORDER #: 04 -E© - HF(j �© <br /> a6o�eaEonfes, rna. <br /> Cooler of t <br /> SAMPLE RECEIPT FORM <br /> CLIENT: V-ivFr- 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. OC IR thermometer. <br /> Chilled an6placed in cooler with wet ice. Ambient temperature. <br /> Ambient and placed in cooler with wet ice. <br /> Ambient temperature. <br /> °C Temperature blank. Initial: U05 <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... ............ f <br /> ... .... ... ... . <br /> Correct containers for analyses requested.................... . <br /> Proper preservation noted on san pole:;label(s)..................................... ... ... . <br /> VOA vial(s)free of headspace. ;-..................................................... ... ... . <br /> l <br /> Tedlar bag(s)free of condensation................................................... <br /> Initial: _ <br /> COMMENTS: <br /> 4 <br /> 4 <br /> 1 <br />