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Page 9 of 9 <br /> WORK ORDER #: 08 - © - 0 © 3C2 <br /> Cooler . of C <br /> SAMPLE RECEIPT FORM <br /> CLIENT: V—�rV- DATE: <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. t °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: UYI) <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No (Not Intact) : Not Present: <br /> Initial: <br /> SAMPLE CONDITION: <br /> c Yes No N/A <br /> Chain-Of-Custody locument(s)received with samples......................... <br /> Sampler's name indicated on COC................................................. <br /> Sample container label(s)consistent with custody papers..................... <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 /> ... ... . ... .... <br /> VOA vial(s)free of headspace. ....................................................... <br /> —� <br /> Tedlar bag(s)free of condensation.......... <br /> Initial: <br /> COMMENTS: <br />