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TestAmerica <br /> ANALYTt[AL TESTING CORPORATION <br /> Nashville Division <br /> COOLER RECEIPT FORM BC# <br />' 421338 <br /> Client Name ETIC Engineering <br />' Cooler Received/Opened On 6/30/05 Accessioned By: James D. Jacobs <br /> I <br /> 1 Log-in n Signature <br /> 1. Temperature of Cooler when triaged Degrees Celsius <br />' 2 Were custody seals on outside of cooler? 9E NO NA <br /> a If yes,how many and where <br /> I3 Were custody seals on containers? YES NA <br />' 4 Were the seals intact,signed,and dated correctly? j' NO NA <br /> 5 Were custody papers inside cooler' -T- NO NA <br />' 6 Were custody papers properly filled out(ink,signed,etc)? NO NA <br /> 7 Did you sign the custody papers in the appropriate place? NO NA <br />' . 8 What fund of packing material used? ubblewr Peanuts Vermiculite Foam Insert <br /> Ziplock baggies Paper Otber None <br />' 9 Cooling process Ice Ice-pack Ice(direct contact) Dry ice Other None <br /> 10 Did all containers arrive in good condition(unbroken)? Lfi O NA <br /> 1 <br />' 11 Were all container labels complete(#,date,signed,Pres,etc)? NO NA <br /> 12 Dud all container labels and tags agree with custody papers? NO NA <br />' 13 Were correct containers used for the analysis requested? E NO NA <br /> 14 a Were VOA vials received? E NO NA <br />' b Was there any observable head space present in any VOA vial? f0 YES NA <br /> 15 Was sufficient amount of sample sent in each container9 L'E� NO NA <br />' 16 Were correct preservatives used? . 9E NO NA <br /> If not,record standard ID of preservative used here <br />' 17 Was residual chlorine present? NO YES 6 <br /> 18 Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below <br />' 5947,5958 <br /> ed- x UPS Velocity DHL Route Off-street Misc <br />' 19 If a Non-Conformance exists,see attached or comments below <br /> I vJ-,tI 0-r-s -Fe- VrV�-3. <br />' BIS=Broken in shipment <br /> Cooler Receipt Form LF-1 Revised 415105 <br /> End of Form <br />