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Page 12 of 12 <br /> Oft <br /> ❑ ❑ EaoFWORK ORDER #: OJ - O `.� - <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: VAS DATE: '�5 -29k l <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 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: W <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No(Not Intact) : Not Applicable(N/A): <br /> Initial: W� <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-Of-Custody document(s)received with samples......................... <br /> Sample container label(s) consistent with custody papers..................... / <br /> ... .... ... ... . <br /> Sample container(s)intact and good condition................................... <br /> ... ... . ... ... . <br /> Correct containers for analyses requested......................................... <br /> Proper preservation noted on sample label(s)........... <br /> VOA vial(s)free of headspace. .......... <br /> .. <br /> Tedlar bag(s)free of condensation............ . <br /> Initial: �'J <br /> COMMENTS: <br />