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TestAmerica Canton Sample Receipt Form/Narrative Login# <br /> Canton Facilitv Cooler unpacked by: <br /> Client_ GD- Tvn Site Name _ <br /> Cooler Received on 67- Opened on 1 u0-.j )t <br /> FedEx:1° Grd x UPS FAS Stetson Client DropOff TestAmerica Courier Other <br /> StorageLocation <br /> Receipt Tter-ho s:Drop-oflDate/lime <br /> TestAmerica Cooler# Foam Box Client ler Box Other <br /> Packing material usedk Bu a rap Foam P I Bag None Other <br /> COOLANT: et ce Blue lce Dry Ice Water None <br /> I. Cooler temperature u n ipl ❑ See Multiple Cooter 170M <br /> IR GUN#IR-8(CF +0.4+0.49C) Observed Cooler Temp..q--°C Corrected Cooler Temp. ( ' °C <br /> IR GUN 436 (CF +13-C) Observed Cooler Temp. °C Corrected Cooler Temp. °C <br /> 2, Were custody seals on the outside of the cooler(s)? If Yes Quantity_ es No <br /> -Were custody seals on the outside of the cooler(s)signed S dated? Nt�o. NA <br /> -Were custody seals on the bottle(s)or bottle kits(LLHg/MeHg)? "Da <br /> 3. Shippers'packing slip attached to the cooler(s)? YepNO <br /> 4, Did custody papers accompany the sample(s)? Y sr�No <br /> 5. Were the custody papers relinquished B.signed in the appropriate place? 'WU No I <br /> 6, Was/were the person(s)who collected the samples clearly identified on the COC? Yes 16 <br /> 7. Did all bottles arrive in good condition(Unbroken)? No _ <br /> -- 8. Could all bottle labels be reconciled With the COC? No <br /> -- <br /> 9. Were correct bottle(s)used for the test(s)indicated? No r <br /> 10. Sufficient quantity received to perform indicated analyses? No F <br /> 11. An these work share samples? I No <br /> If yes,Questions 11-15 have been checked at the originating laboratory. <br /> 11. Were sample(s)at the correct pH upon receipt? Yes o NA pli Strip Loth HC682547 } <br /> 12. Were VOAs on the COC? Yes ° <br /> 13. Were air bubbles>6 mm in any VOA vials? Y No NA <br /> 14. Was a VOA trip blank present in the cooler(s)? Trip Blank Lot# Y No <br /> 15. Was a LL Hg or Me Hg trip blank present? NO <br /> Contacted PM Date by via Verba Voice Mail Other <br /> Concerning <br /> 16. CRAIN OF CUSTODY&SAMPLE DISCREPANCIES <br /> Samples processed by: <br /> i <br /> I <br /> i <br /> 17. SAMPLE CONDITION <br /> Samples) were received after the recommended holding time had expired. <br /> Sample(s) were received in a broken container. <br /> Sample(s) were received with bubble>6 mm in diameter.(Notify PM) <br /> 18. SAMPLE PRESERVATION <br /> Sample(s) were further preserved in the laboratory. <br /> Time preserved: Preservative(s)Added/Lot number(s); <br /> Ref.'SORNCSG0005,Sample Re iriag <br /> L:IQA000A pepanmenl12A rARDlSIDpOMM Cvx,roh ,a,%lntmsaiwoVn Rev[rfsn1074C.OP9J0/116 Caster lhceipl Fwm.dw djl <br /> Page 24 of 27 11/7/2016 <br />