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• • Page 10 of 10 <br /> WORK ORDER #: 06 - <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: V--krrV DATE: \O -CAo <br /> TEMPERATURE—SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY(Other than Caiscience Courier): <br /> Chilled, cooler with temperature blank provided. °J•Z '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 /> °CTemperatureblank. Initial: lJ <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No(Not Intact) : Not Applicable(N/A): <br /> Initial: w f <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of-Custody document(s)received with samples......................... / <br /> Sample container label(s)consistent with custody papers..................... <br /> Sample container(s)Intact and good condition......................... �_, <br /> Correct containers 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: W`l <br /> COMMENTS: <br />