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TestAmei ��ca <br /> ANAEYrICAE TESTING LORPDRATiDN <br /> Nashville Division <br /> COOLER RECEIPT FORM BC# <br /> 41@538 <br /> Client Name ETIC Engineering <br /> Cooler Received/Opened On: 3/24105 Accessioned By: James D. Jacobs <br />' <br /> Log-in Per nn Signature <br /> I Temperature of Cooler when triaged- Degrees Celsius <br /> 2 Were custody seals on outside of cooler? YESN(� NA <br /> a If yes,how many and where �f <br /> 3 Were custody seals on containers? NO YES NA <br /> 4 Were the seals intact,signed,and dated correctly? YES NO <br /> 5 Were custody papers inside cooler? Ls' NO NA <br />' 6 Were custody papers properly filled out(ink,signed,etc)? L Ems' NO NA <br /> 7 Did you sign the custody papers in the appropriate plate? E5 NO NA <br /> 8 What kind of packing material used? Bubblewrap Peanuts Vermiculite Other None <br /> 9 Cooling process � Ice-pack Ice(direct contact) Dry ice Other None <br /> 10 Did all containers arrive in good condition(unbroken)9 gE <br /> NO NA <br /> 11 Were all container labels complete(#,date,signed,pres,etc)? NO NA <br /> 12 Did all container labels and tags agree with custody papers? E NO NA <br /> 13 Were correct containers used for the analysis requested? E NO NA <br /> 14 a Were VOA vials received? YE 1 NO NA <br /> b Was there any observable head space present in any VOA vial? NO YES NA <br /> 15 Was sufficient amount of sample sent in each container? E NO NA <br /> 16 Were correct preservatives used? YES NO NA <br /> If not,record standard 1D of preservative used here /'� <br /> 17 Was residual chlorine present? NO YES( <br /> N�► J <br /> 18 Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below �/ <br /> 7104 <br /> • ed-Ex UPS Velocity DHL Route Off-street Misc <br /> 19 If a Non-Conformance exists,see attached or comments below <br /> Cooler Receipt Form LF-1 Revised 12/9/04 <br /> FnA of Fnrm <br />