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�u <br /> � ®���►oma,-rz��Nicr-�r WORK ORDER # OZ- C� 7 F1 <br /> . �ab�ra!i[►rfes lr�c. <br />' F�] <br /> Cooler of <br /> SAMPLE RECEIPT FORM <br /> CLIENT RIP DATE Z i 12- <br /> TEMPERATURE <br /> — SAMPLES RECEIVED BY <br /> CALSCIENCE COURIER LABORATORY (Other than CSIscience Courser) <br /> Chilled, cooler with temperature blank provided °C Temperature blank <br /> Chilled, cooler without temperature blank 'C IR thermometer <br /> 1 fr <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 /> ;Sample(s) <br /> USTODY SEAL INTACT <br /> 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 ✓J <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) l <br /> VOA vial(s)free of headspace <br />' Tedlar bag(s) free of condensation <br /> Initial _ { <br /> 1 <br /> COMMENTS <br /> 1 <br />