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TESTAMERICA,INC.-NASHVILLE <br />' COOLER RECEIPT FORM <br /> Client <br /> Cooler Received On qWrL And Opened On By: Mark Beasley ,_ <br /> (Signature) <br />' 1 Temperature of Cooler when opened 3C Degrees Celsius_____ <br /> 2 Were custody seals on outside of cooler? .. .. .. . YES N/A <br /> a If yes, how many, what kind and where <br />' b Were the seals intact, signed, and dated correctly? . .. . . YES NZ NIA <br /> 3. Were custody seals on containers and intact?........................ ......... YES NIA <br /> 4. Were custody papers inside cooler? . ... ... .. 'F5 NO NIA <br />' 5. Were custody papers properly filled out (ink,signed,etc)? . . . . .. 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? ubblew�eanuts Vermiculite Other None <br /> S. Was sufficient ice used (if appropriate)? . . .. . ... .. . .. .. . . � NO N/A <br /> 9. Did all bottles arrive in good condition(unbroken)? . . . . . . (�FD NO NIA <br /> t10. Were aII bottle labels complete (#,date,signed,pres,etc)? . .. . .. .. . ...� NO NIA <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? . . . . . NO NIA <br /> 13. a. Were VOA vials received?.................. ................................. YES NO NIA <br /> b Was there any observable head space present in any VOA vial?...... NO )YES NIA <br /> 14 Was sufficient amount of sample sent in each bottle? YF�' NO N/A <br /> 15 <br /> Were correct preservatives used? .. .. . . . ... YES NO NIA <br />' If not, record standard ID of preservative used here <br /> 16 Was residual chlorine present?.. ....... ................ ............. ......... ..NO YES N/A <br /> 17. Corrective action taken,if necessary: <br /> See attached for resolution <br /> Cooler Receipt Form LF-1 9/17/02 <br /> 1 <br />