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TestAmerlc� <br /> ANALYTICAL Tf5Tl1•!G CORPORATIDN <br /> Nashville Division <br />'• COOLER RECEIPT FORM BC# <br /> 399173 <br /> Client Name : m C-11-1 <br /> _•--- <br />' Cooler Received/Opened On: 12/7/04 Accessioned By: Mike McBride <br /> Log-en Personnel Signature <br /> 1. Temperature of Cooler when triaged. 614- Degrees Celsius <br /> 2 Were custody seals on outside of cooler? NO NA <br /> a. If yes,how many,what land and where_Ci)!vgj- <br /> 3 Were custody seals on containers?.. .. T YES NA <br />' 4. Were the seals intact,signed,and dated correctly? NO NA <br /> ' 5 Were custody papers inside cooler? .. . . NO NA <br />' 6 Were custody papers properly filled out(mk,signed,etc)? (!PD. NO NA <br /> 7 Did you sign the custody papers in the appropriate place?. (ITP NO NA <br /> • 8 What hind of packing material used? u ble Peanuts Vermiculite Other None <br /> 9 Cooling process � Ice-pack Ice(direct contact) Dryice Other None <br />' 10 Did all containers arrive in good condition(unbroken)? � NO NA <br /> 11 Were all container labels complete(#,date,signed,pres,etc)? (jng?NO NA <br /> 12 Did all container labels and tags agree with custody papers? NO NA <br /> 13 Were correct containers used for the analyses requested? 10 NO NA <br /> 14 a. Were VOA vials received? .. ig&.NO NA <br /> b Was there any observable bead space present in any VOA veal? YES NA <br />' 15 Was sufficient amount of sample sent in each container? i NO NA <br /> 16 Were correct preservatives used9 .. .. NO NA <br />' If not,record standard 113 of preservative used here <br /> 17 Was residual chlorine present? .. NO YES <br />' 18 Indicate the Airbill Tracking Number past 4 digits for Fedex only)and Name of Courier below <br /> I,(p2 <br /> ed-1i. UPS Velocity DlE, Route Off-street Misc <br /> 19 If a Non-Conformance exists,see attached or comments below <br /> i <br />' Cooler Receipt Form LF-1 Revised 125104 <br /> End of Form <br />