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�iti�! 0o Inn. WORK ORDER #: 02-El ❑ ❑ © ® 19r==M"t <br /> 46 Cooler � of <br /> SAMPLE RECEIPT FORM <br /> CLIENT )'(4 Fr- DATE: I u v $--- <br /> TEMPERATURE — SAMPLES RECEIVED BY: <br /> CALSCIENCE COURIER: LABORATORY (Other than Calscience Courier): <br /> Chilled, cooler with temperature blank provided Z °C Temperature blank <br /> Chilled, cooler without temperature blank °C IR thermometer <br /> Chilled and placed in cooler with wet ice Ambient temperature <br /> Ambient and placed in cooler with wet ice <br /> Ambient temperature <br /> OC Temperature blank Initial �-- <br /> CUSTODY SEAL INTACT: / <br /> Sample($) Cooler ✓ No (Not Intact) Not Applicable (NIA) <br /> Initial <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 - v <br /> Initis[ <br /> COMMENTS: <br />