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TE STAMERICA INC.-NASHVILLE <br /> COOLER RECEIPT FORM <br /> Client B <br /> _ <br /> Cooler Received On 1 o And Opened On �By. Ben Wright <br />' {Signat <br /> 1 'Temperature of Cooler wheu opened •( Degrees Celsius <br />' 2 Were custody seals on outside of cooler" YES O+ N/A <br />' a If yes, how many,what land and where V�& <br /> b Were the seals intact, signed, and dated correctly? YES NO /A <br />' 3. Were custody seals on containers and mtact9 .. . ............ . YES N/A <br /> 4 Were custody papers inside cooler"' NO NIA <br /> S Were custody papers properly filled out(ink,signed,etc)? '(.YIOS NO N/A <br /> 6 Did you sign the custody papers in the appropriate place? YE NO N/A <br /> 7 What kind of packing material used? xbblewra Peanuts Vermiculite Other None <br /> fS Was sufficient ice used (if appropriate) . . . ....4 CYES )NO N/A <br /> 9. Did all bottles arrive in good condition( unbroken)9 . . 'Ir-615E NO N/A <br />' 10 Were all bottle Iabels complete (#,date,signed,pres,etc)9 YES NO N/A <br />' 11 Did all bottle labels and tags agree with custody papers' YE'$ NO N/A <br /> 12 Were correct bottles used for the analysis requested' .YES NO N/A <br /> f13 a Were VOA vials received*7... . . ...... ............ ... ........ OYES NO NIA <br /> b Was there any observable bead space present in any VOA vial9.... YES N/A <br /> 14 Was sufficient amount of sample sent in each bottle'7. . YP NO N/A <br />' 15 Were correct preservatives used9. YE NO N/A <br /> If not, record standard ID of preservative used Here <br /> 1 16 Was residual chlorine present9 .. .... ....... .... NO YES NI <br /> 17. Corrective action taken, if necessary- <br /> See <br /> , <br /> See attached for resolution <br /> Cooler Receipt Form LF-I 9/17/02 <br />