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.TUN-04-2003 15:58 P.05 <br /> mi i Nor" WORK ORDER . 03 _ d 1 <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> w <br /> '00,LCLIENT: 140 DATE: -d <br /> TEMPERATURE—SAMPLE RECEIVED BY. <br /> CALSCIENCE COURIER. LABORATORY(other than Caisclence Courier): <br /> Chilled,cooler with temperature blank provided. °C Temperature blank. <br /> Chilled,cooler without temperature blank °G 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--AzNo(Not in ): Not Applicable(NIA): <br /> Initial: <br /> SAMPLE DITTO <br /> Yes No WA <br /> Chain-Of-Custody documant(a)received with samples......................... ...._.. ....... <br /> Sample container label(s)consist®nt with cudody papers..................... A� ._..... ... .,.. <br /> Sample container(a)Intact and good condition................................... gj!� _.......Correct .... <br /> containers for analyses requested......................................... z....... ,..... <br /> Proper preservation noted on sample label(s)...................................... ......^z <br /> VOAvlaks)free of headspaae. ....................................................... ... .... ....... dz�_ <br /> Tedlar bag(s)free of condensation................................................... ....... ....... <br /> Initial: <br /> COMMENTS: <br />