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� TestAmeri!4 <br /> Nashville Division <br /> COOLER RECEIPT FORM BC# <br /> TIC <br /> ! <br /> Client C !l , <br /> Cooler Received On 12/10/03And Opened On:12/10/03By:Shane Gambill <br />' (Signature) <br />' 1. Temperature of Cooler when opened -2 D Demes Celsius <br /> 2 Were custody seals on outside of cooler' .. CYIE <br /> NO .NA <br />' a If yes, how many,what kind and where /3/4RONT ACK/SIDE <br /> 3. Were custody seals on containers and intact? . .. . NO YES QNA <br /> I � <br /> 4 Were the seals intact, signed, and dated correctly' .. .YES . NO NA <br />' 5. Were custody papers inside cooler' .. YES NO NA <br /> 6 Were custody papers properly filled out (mk,signed,etc)� ES NO . NA <br />'. 7 Did you sign the custody papers in the appropriate place' E� .NO NA <br />' 8 What kind of packing material used' �uf6�blewrapPeanuts Vermiculite Other None <br /> 9 Cooling process ` Ice Ice pack Ice(direct contact) Dry ice Other None <br />' 10 Did all containers arrive in good condition( unbroken)9 . . . . . .G) NO NA <br /> 11 Were all container labels complete (#,date,signed,pres,ete)? Q 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'. Y NO NA <br /> I 14 a Were VOA vials received <br /> Y NO NA <br />' b Was there any observable head space present in any VOA, vial? 0 YES NA <br /> 15 Was sufficient amount of sample sent in each container' YES NO NA <br /> 16 Were correct preservatives used' .� N0 NA <br /> If not, record standard ID of preservative used here <br />' 17 Was residual chlorine present NO YES r <br /> 18 See attached for i esolution of non-conformance <br /> Ir <br /> (Fed-)x UPS velocity Airborne Route Off-street Misc <br /> C:oolei Receipt Folm LF-1 914103 End ISI Fomi <br />