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Testj�merica <br /> ANALttiCAL FES7ING CORPORATION <br /> Nashville Division <br /> COOLER RECEIPT FORM BC# <br />' 398936 <br /> Client Name • ETIC Engineerine <br /> Cooler Received/Opened On: 1214104 Accessioned By: -James D. Jacobs <br />' Log-in P64Wei Signature <br /> I. Temperature of Cooler when triaged: Degrees Celsius <br /> 2 Were custody seals on outside of cooler' GE NO NA <br />' a If yes,how many,what kind and where <br /> 3 Were custody seals on containers9 aN YES NA <br /> 4. Were the seals intact,signed,and dated correctly' YE NO NA <br /> 5 Were custody papers inside cooler9 . . NO NA <br /> 6 Were custody papers properly filled out(ink,signed,etc)? NO NA <br /> 7 Did you sign the custody papers in the appropriate place? 1i NO NA <br /> 8 What kind of packing material used' lewrap Peanuts Vermiculite Other None <br /> 9 Cooling process Ice-pack Ice(direct contact) Dry ice Other None <br /> I10 Did all containers arrive in good condition(unbroken)9 YES 0 NA <br /> 11. Were all container labels complete(#,date,signed,pres,etc)" aE <br /> NO NA <br /> 12 Did all container labels and tags agree with custody papers NONA <br /> 13 Were correct containers used for the analysis requested9E NO NA <br /> 14 a Were VOA vials received9 YE NO NA <br /> b Was there any observable head space present in any VOA vial? ® YES NA <br /> 15 Was sufficient amount of sample sent in each containerszS <br /> NO NA <br /> 16 Were correct preservatives used NONA <br /> IIf not, record standard ID of preservative used here <br /> 17 Was residual chlorine present' NO YES ( NQ J <br /> 18 Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below ` <br />' 2357 <br /> ed-E UPS Velocity DHL Route Off-street Misc <br /> 0 19 If a Non-Conformance exists,see attached or comments below <br /> 1 <br /> Cooler Receipt Form LF-1 Revised 12/3/04 <br /> End of Form <br />