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Page 16 of 16 <br /> ' I WORK ORDER #: 07 - 72- <br /> Cooler of <br /> ' SAMPLE RECEIPT FORM <br /> CLIENT: -\�F Kp,���cA� DATE:_4AO (Da <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. '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: WV5 <br /> ' CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: / No (Not Intact) : Not Present: <br /> ' Initial: U3 <br /> SAMPLE CONDITION: <br /> ' Yes No N/A <br /> Chain-Of-Custody document(s)received with samples......................... . . <br /> Sampler's name indicated on COC................................................. <br /> ... ... . ... ... . <br /> ' Sample container label(s)consistent with custody papers..................... l <br /> ... .... ... ... . <br /> Sample container(s) intact and good condition................................... <br /> ... .... ... ... . <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................................................... <br /> Initial: �J <br /> ' COMMENTS: <br /> I <br /> 1 <br />