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TestAmerica <br /> I ANALYTICAL TE5TING CORPORATION <br /> Nashville Division <br />' COOLER RECEIPT FORM BC# <br /> 3897! <br /> Client Name : ETIC Engineering <br />' Cooler Received/Opened On: 9/17/04 Accessioned By: James D. Jacobs <br /> Ir1QW-11 I <br /> Log-in o el ignature <br />' 1. Temperature of Cooler when triaged: Degrees Celsius <br /> 2 Were custody seals on outside of cooler) NO NA <br /> a If yes,how many,what kind and where <br /> 3 Were custody seals on containers and intact) NO YES NA <br /> i <br /> 4. Were the seals intact,signed,and dated correctly' NO NA <br /> 5 Were custody papers Inside cooler) YE NO NA <br /> Ib Were custody papers properly filled out Cmk,signed,etc)? NO NA <br /> 7 Did you sign the custody papers in the appropriate place? YE NO NA <br /> 8 What kind of packing material used) Bubblew p peanuts Vermiculite Other None <br /> 9 Cooling process Ice Ice-pack lee(direct contact) Dry ice Other None <br /> 10 Did all containers arrive in good condition(unbroken)) YES (5)NA <br /> 11 Were all container labels complete(#,date,signed,pres,etc)) YE NO NA <br /> 12 Did all container labels and tags agree with custody papers? YE NO NA <br /> 13 Were correct containers used for the analysis requested) E / NO NA <br /> I14 a Were VOA vials received) YE NO NA <br /> b. Was there any observable head space present in any VOA vial) N YES NA <br /> I15 Was sufficient amount of sample sent in each container) YE NO NA <br /> 16 Were correct preservatives used) . YE NO NA <br /> IIf not,record standard ID of preservative used here <br /> 17 Was residual chlorine present' NO YES 1 NQ J <br /> 18 Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below <br /> I 7378 <br /> (!Fii) <br /> UPS Velocity Airborne Route Off-street Misc <br /> 19 If a Non-Conformance exists,see attached or comments below <br /> Cooler Receipt Form LF-1 Revised 3/3/04 <br /> End of Form <br />