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- WORK ORDER #: 08 - D - a a a <br /> o 1'C. Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT:�-X-t� DATE: <br /> TEMPERATURE – SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. _ 3 . �a °C Temperature blank. <br /> Chilled, cooler without temperature blank. _ —.-0 <br /> _°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 /> °CTemperature blank. Initial: W\12 <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No (Not Intact) : Not Present: <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No NIA <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..................... '7 ... ... . ... ... . <br /> Sample container(s) intact and good condition................................... ... ... . ... ... . <br /> Correct containers and volume 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................................................... ... ... . Z' <br /> Initial: w <br /> COMMENTS: <br />