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Page 9 of 9 <br /> 0 <br /> r t WORK ORDER #: OG - [� ❑� - D <br /> tgrtgar erre. <br /> Cooler Of <br /> SAMPLE RECEIPT FORM <br /> CLIENT: I I • � DATE: <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided. 3 3 °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: <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler.—\'-'-� No(Not Intact) : Not Applicable(N/A): <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No N/A <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. _. ............_.........._.................._..... ... ... . N/ <br /> Tedlar bag(s)free of condensation..................... ............................. ... ... . ... ... . <br /> Initial: <br /> COMMENTS: <br />