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TEST AMERICA ANALYTICAL <br /> r TESTING CORP.-NASHVILLE <br /> COOLER RECEIPT FORM BC# 35 ' 1 <br /> Client [� TT <br /> r j-- <br /> Cooler Received On: 6113/03And Opened On: 6/13/03By:Shane Gambill <br /> r (Signature) <br /> r1 Temperature of Cooler when opened 6 ]De Tees Celsius <br /> 2 Were custody seals on outside of cooler?. . . . .. .. ..YES NO. NA <br /> ta If yes, how many,what kind and where.1/2/3/4 FRONT/BACK/SIDE <br /> 3 Were custody seals on containers and intact? . . . . .... ... . ........ NO YES. <br /> 4 Were the seals intact, signed, and dated correctly?. ..... .... .. . .. .. .YES ..NO .p <br />' 5 Were custody papers inside cooler9 ... . . ..... ... . . ... YES NO . NA <br /> 6 Were custody papers properly filled out(ink,signed,etc)? .. 4 .NO . NA <br /> 7 Did you sign the custody papers in the appropriate place9. . ..JCD .NO. NA <br /> 8 What kind of packing material used ubblewrap eanuts Vermiculite Other None <br /> i <br /> 9 Was sufficient ice used (if appropriate)? ... ... . .. .. . .....YES NO . NA <br />' 14 Did all bottles arrive in good condition(unbroken.)? (M5-NO . NA <br /> 11 Were all bottle labels complete (#,date,signed,pres,etcy? .. . . .�NO . NA <br /> 12. Did all bottle labels and tags agree with custody papers" ... . �NO NA <br />' 13. Were correct bottles used for the analysis requested?. . . .. .. . . ..�NO NA <br /> 14. a. Were VOA vials received? ... ... ... .. NA <br /> b. Was there any observable head space present in any VOA vial9 ... aNO . <br /> ES...NA <br /> 15 Was sufficient amount of sample sent in each bottle" ... CRS NO., NA <br /> 16. Were correct preservatives used? ..... . . ... . .. ...... � NO. NA <br /> If not,record standard ID of preservative used here <br /> 17 Was residual chlorine present' . . ... . . . . . . . NO. YESNA <br /> 18,_See attached for resolution of non-conformance: <br /> \Fed-Ex UPS Velocity Airborne Route Off-street Misc. <br />' Cooler Receipt Form Ll{-1 316103 <br />