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Page 24 of 24 <br /> ' <br /> CktMir" WORK ORDER #: 07 <br /> Zabarat ass nc' Cooler 2- of 2 <br /> SAMPLE RECEIPT FORM <br /> N �� ca,` Z � <br /> CLIENT: �P� A � DATE: <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> LABORATORY (Other than Calscience Courier): <br /> 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: Wy7 <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 with samples......................... <br /> Sampler's name indicated on COC................................................. <br /> Sample container label(s)consistent with custody papers..................... / : :i: .. .. <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 /> VOA vial(s)free of headspace. ....................................................... ... ... . <br /> Tedlar bag(s)free of condensation................................................... ... ... . / <br /> Initial: <br /> COMMENTS: <br />