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Page 8of8 <br /> elsc�err;c� <br /> v)rarrrrrenEa! <br /> ebar�rorles, lnc. WORK ORDER #: O5 - Fcl� a _ o © a a <br /> Cooler \ of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: DATE: 't> -2- 41 �5 <br /> TEMPERATURE - SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. �J•� °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: 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......................... f <br /> ... .... ... ... . <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 /> ... .... ... .... <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 />