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Page 23 of 24 <br /> ,WIr7d, <br /> WORK ORDER #: 07 - [-01 Pz- - D PL P5 E <br /> :. ato.deay )IT ca Cooler of 2 <br /> SAMPLE RECEIPT FORM <br /> r <br /> CLIENT.• �-�Pr v(,�"c.X\�- DATE: 2� �013-� <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. '� °C Temperature blank. <br /> r 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: <br /> r <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: / No(Not Intact) : Not Present: <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <br /> Chain-Of-Custody document(s)received w4h 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....................... "I-- <br /> Proper <br /> Proper preservation noted on sample label(s).....................................�• <br /> VOA vial(s)free of headspace. ....................................................... <br /> Tedlar bag(s)free of condensation................................................... <br /> ' Initial: <br /> ' COMMENTS: <br /> r <br /> i <br /> 1 <br /> 1 <br />