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1 TestAmerica <br /> ANALYTICAL TESTING CORPORATION <br />' Nashville Division <br /> COOLER RECEIPT FORM BC# <br />' 399172 <br /> Client Name . ofic L�,� <br />' Cooler Received/Opened On: 12/7/04 Accessioned By: Mike McBride <br /> Log-in Personnel Signature <br /> I Temperature of Cooler when triaged. 5 L� Degrees Celsius <br /> I2 Were custody seals on outside of cooler? NO NA <br />' a. If yes,how many,what bind and where <br /> 3 Were custody seals on containers? (ND YES NA <br /> I4. Were the seals intact,signed,and dated correctly? (g3� NO NA <br /> 5 Were custody papers inside cooler? OD NO NA <br /> 6 Were custody papers properly filled out(ink,signed,etc)9 NO NA <br /> 7 Did you sign the custody papers in the appropriate place9 41` NO NA <br /> lie8 What land of packing material used? 49bblewra Peanuts Vermiculite Other None <br /> 9 Cooling process (S5 Ice-pack Ice(direct contact) Dry ice Other None <br />' 10 Did all containers arrive In good condition(unbroken)? <lEg> NO NA <br /> 11 Were all container Iabels complete(##,date,signed,pres,etc)9 <j�g?NO NA <br /> 12 Did all container labels and tags agree with custody papers9 efl[�R> NO NA <br /> 13 Were correct containers used for the analysis requested? NO NA <br /> 14 a. Were VOA vials received9 NO NA <br /> b Was there any observable head space present in any VOA vial9 Colt YES NA <br /> 15 Was sufficient amount of sample sent in each container? E�NO NA <br /> 16 Were correct preservatives used? ES NO NA <br /> If not,record standard ID of preservative used here <br /> 17 Was residual chlorine present9 NO YES <br /> 18 Indicate the Airbdl Tracking Number(last 4 digits for Fedex only)and Name of Courier below <br /> 7.a(r Z� _ <br /> ed-Ex S UPS Velocity DHL Route Off-street Misc <br /> 19 I€a Non-Conformance exists,see attached or comments below <br /> Cooler Receipt Form LF-1 Revised 1213/04 <br /> End of Form <br />