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TestAmerica <br /> ANAtYrItAt TESTING CORPORATION <br /> Nashville Division <br /> COOLER RECEIPT FORM BC# <br /> 377329 <br /> Client Name : �; T JG <br /> Cooler Received/Opened On: 512104 Accessioned By: Shawn Gracey <br /> IL <br /> Log_m Personnel Sign re <br /> 1. Temperature of Cooler when triaged: Degrees Celsius <br /> 2 Were custody seals on outside of cooler? . . S .NO NA <br /> a. If yes,how many,what kind and where d <br /> 3 Were custody seals on containers and intact? N YES NA <br /> 4. Were the seals intact,stgDed,and dated correctly'' LYES) NO NA <br /> 5 Were custody papers inside cooler9 YE .NO NA <br /> b Were custody papers properly filled out(ink,signed,etc)? YES NO NA <br /> 7 Did you sign the custody papers in the appropriate lace? YES NO NA <br /> 8 What kind of packing material used? bblewra eanuts Vermiculite Other None <br /> 9 Cooling process C),ce-pack Ice(direct contact) Dry Ice Other None <br /> 10 Did all containers arrive to good condition(unbroken)' dNO <br /> NO NA <br /> 11 Were all container labels complete(#,date,signed,pres,etc)? NA <br /> 12 Dad all container labels and tags agree with custody papers' YES NO NA <br /> 13 Were correct containers used for the analyses requested' YES NO NA <br /> 14 a. Were VOA vials received? /YENO 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 to each contalner? YE5 NO NA <br /> 16 Were correct preservatives used? YE NO NA <br /> If not,record standard ID of preservative used here <br /> 17 Was residual chlorine present? NO YES ivE a� <br /> 18 Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courter below <br /> U' <br /> ed- 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!3104 <br /> End of Form <br />