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1 <br /> TEST AMERICA, INC:NASHVILLE <br /> COOLER RECEIPT FORM <br /> ' Client: SES se" a93 <br /> ' Cooler Received On_7.1-7oI And Opened On: -7-(-7'02 By: i�te �YC�iTlde <br /> (SIP'Oure) I> <br /> 1, Tempest¢of Cooler when opened ;t,o l�ei?reCs Cetsius <br /> ' 2. Were custody seals on outside of cooler and intact?.................................... . E8 O <br /> ' a. If yes,what kind and where: (i ON ACKMIDE <br /> b. Were the signature and data correct?.................................... <br /> .......�1Q0 <br /> ' c Were custody seat on contWners and bdaW....................................... YES® <br /> 3. Were custody papers inside cooler?...........................................................�0 <br /> ' 4. Were custody papers properly fined out(ink signedretc)?.............................49NO <br /> S. Did you sign the custody papers in the appropriate place?............................ o <br /> ' 6. What kind of packing mate 1TSyEIZMIC'�n 17 NOS <br /> ' 7. Was sufficient ice used (if appropriate)?................................................... QO <br /> e Did all bottles arrive in good condition(unbroken)?...................................eFo0 <br /> ' 9. Were an bottle labels complete (#t,date�ed pros,etc)?...............................�Q <br /> ' la Did an bottle labels and tags agrwith custody papers?............................... FS o <br /> 11. Were correct bottles used and present for the analysis requested?............... fl <br /> ' 12. Were VOA Vials preseat?.............................................................................YR61� <br /> a if so were air bubbles present?................................................ <br /> I. ✓'_ <br /> 13. Was sufacimt amount of sample sent m each bottle?........................ ........�O <br /> 14. Were correct preservatives nsed?............................................................ <br /> 15. Was residual chlorine present?..................................................I......... <br /> ' 16. Corrective action taken, if necessary: <br /> a. Name of person contacted: <br /> b, Date: <br /> ' LF-I IQJ8J99 <br /> Cooler Receipt Form <br />