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TestAmerica <br /> ANALYTICAL TESTING CO RPO RAi[ON <br />' Nashville Division <br /> COOLER RECEIPT FORM BC# <br />' _ 368723 <br /> Client Name �r [_ <br />' Cooler Received/Opened On.03/23/04 Accessioned By:Benjamin C.Wri2ht <br /> 4 ef L-�__��_ <br />' o - ersonnel Signature <br /> 1 Temperature of Cooler when triaged` Degrees Celsius <br /> I2 Were custody seals on outside of cooler' Qj:- NO NA <br />' a If yes,how many,what kind and where_ rr 1 .�1 - r=70MA_j- <br /> 3 Were custody seals on containers and intact9 YES NA <br /> 4 Were the seals intact,signed,and dated correctly"' YT,ySF � NO NA <br /> 5 Were custody papers inside coolers YF NO NA <br /> 6 Were custody papers properly filled out(ink,signed,etc)9, S NO NA <br />' 7 Did you sign the custody papers in the appropriate place? E5�.NO NA <br />' 8 What[and of packing material used blewra 'Peanuts Vermiculite Other None <br /> 9 Cooling process Eiece Ice-pack Ice(direct contact) Dry ice Other None <br />' 10 Did all containers arrive in good condition(unbroken)9 'YES .NO NA <br /> 11 Were all container labels complete(#,date,signed,pres,etc)9 / YE NO NA <br /> 12 Did all container labels and tags agree with custody papers Es NO NA <br /> 13 Were correct containers used for the analysis requested' c� NO NA <br /> 14 a Were VOA vials received' �irr S NO NA <br /> b Was there any observable head space present in any VOA vial? C YES NA <br /> 15 Was sufficient amount of sample sent in each container' (CS NO NA <br /> 16 Were correct preservatives used9 GES NO NA <br /> If not, record standard ID of preservative used here <br /> 17 Was residual chlorine present'? NO YES NA <br /> I18 Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below <br /> _V <br /> j�' UPS Velocity Airborne Route Off-street Misc <br /> 19 If a Nan-Contormance exists,see attached or comments below <br /> u I Im <br />