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Cooler 11)No x L WUKit UKll�K NU. 1d� ✓D <br /> COOLER RECEIPT FORM <br /> PROJECT '7l G•'t�s`3- 3 <br /> COOLER RECEIVED ON 71x3 AND OPENED ON'/Z-�) BY - <br /> (SIGNATURE) <br /> TEMPERATURE UPON RECEIPT: COOLER " oC <br /> TEMP.BLANK /loC <br /> I. Were custody seals on outside of cooler drota t? (::Y:E:0 NO <br /> a. If YES,how many and where- <br /> b. <br /> b. Were signature and date correct. YESNO <br /> 2. Were custody papers taped to lid inside cooler? YES <br /> 3. Were custody papers properly filled out(ink,signed,etc)? 6i)No <br /> 4. Did you sign custody papers in the appropriate place? CZV-D NO <br /> S. Did you attach shipper's packing slip to this form? (!9)NO <br /> 6. What kind of packing material was used? isLo <br /> 7. Was sufficient ice used(if appropriate)? QP NO <br /> 8. Were all bottles sealed in separate plastic bags? GES)NO <br /> 9. Did all bottles arrive in good condition (unbroken)? YE NO <br /> 10. Were all bottle labels complete (no., date,sighed,pres, etc)? NO <br /> 11. Did all bottle labels and tags agree with custody papers? NO <br /> 12. Were correct bottles used for the test indicated? NO <br /> 13. If present,were VOA vials checked for absence of air bubbles and <br /> noted if found? <br /> 14. Adequate volume of VOA vials received per sample? YE <br /> 15. Was sufficient amount of sample sent in each bottle? NO <br /> 1.6. Were correct preservatives used? IrES-71% <br /> 17. Were extra labels added to pre-tared containers? n"o <br /> IS. Corrective action taken, if necessary: <br /> a. Name of person contacted: <br /> b. Date: <br /> CD <br />