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' Page 47 of 59 <br /> WORK ORDER #: 08 - ® - q D ❑D <br /> Cooler 3 of 3 <br /> SAMPLE RECEIPT FORM <br /> CLIENT: � lct DATE: <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 (For Air&Filter Only). <br /> Ambient and placed in cooler with wet ice. <br /> Ambient temperature(For Air&Filter Only). <br /> _ <br /> —0 <br /> C Temperature blank. Initial: <br /> CUSTODY SEAL INTACT: <br /> Sample(s): Cooler: No(Not Intact) : Not Present: <br /> Initial: <br /> SAMPLE CONDITION: <br /> Yes No NIA <br /> Chain-Of-Custody document(s)received with samples......................... L/- ... .... <br /> Sampler's name indicated on COC................................................. ✓ ... .... <br /> ' Sample container label(s)consistent with custody papers..................... ✓ .. •• <br /> Sample container(s)intact and good condition................................... V ... .... <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 />