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JUN-04-2®03 1558 P.05 <br /> tam WORK ORDER#. 03 .22 - ROHE <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> D'CLIENT. ' DATE: 0,04L � <br /> TEMPERATURE--SAMPLES RECEIVED BY. <br /> CALSCiENCE COURIER: LABORATORY(other than Caiscience Courier): <br /> Chilled, 000lerwith 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: _ <br /> CUSTODY SEAL INTACT: <br /> Satnpws): Cooler--AZNo(Not In ): Not Applicable(NIA): _ <br /> Initial, <br /> SAMPLE CONDITION: <br /> Yee No WA <br /> Chale--Of-C document(a)rewived with samples......................... ....... ....... <br /> Sample container label(s)cons with custody papers.... ................ . .... .. .,. <br /> Sample c:ontelner(s)intact and good condition................................... ^....... . ....... <br /> Correct containers for analyses requested........................................ (� ....... <br /> ... <br /> Proper preservation noted on sample label(s)..................................... ......, ......�� <br /> VOAviel(s)free of headspacae. ....................................................... ....... _ <br /> Tedlar bag(s)free of condensation................................................... ....... ....... <br /> Initial: <br /> COMMENTS: <br />