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I <br /> I <br /> I <br /> TestP"rlerlca <br /> THE LEADER IN ENVIRONMENTAL TESTING <br /> Nashville,TN COOLER RECEIPT FORM 720-78844 Chain of-cu-stod.y <br /> Cooler Received/Opened On 4/12/2017f5 <br /> tA <br /> rom Time Samples Removed FCooleme Samples Placed In Storage 7iJ� (2 Hour Window) <br /> 1. Tracking# (last 4 digits,FedEx) Courier: _FedEx_ I <br /> IR Gun ID 160406069 pH Strip Lot 1 ' 1 Chlorine Strip Lot kj(�� <br /> 2. Temperature of rep.sample or temp blank when opened: Degrees Celsius <br /> 3. If Item#2 temperatures is 0°C or less,was the representative sample or temp blank frozen? YES N0..`f�A/ <br /> _0 <br /> 4. Were custody seals on outside of cooler? YES. .NO...NA j <br /> If yes,how many and where: ro/'C. <br /> 5. Were the seals intact,signed,and dated correctly? YE ...NO...NA <br /> 6. Were custody papers inside cooler? gYE .NO...NA <br /> I certify that I opened the cooler and answered questions 1-6(initial) <br /> 7. Were custody seals on containers: YES00 <br /> and Intact YES...NO. , <br /> Were these signed and ed co rectly? YES...NO..� <br /> 8. Packing mat'[used Bubblewr Plastic bag Peanuts Vermiculite Foam Insert Paper 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)? E :..NO...NA <br /> 11. Were all container labels complete(#,date,signed, pres.,etc)? ES ..NO...NA <br /> 12. Did all container labels and tags agree with custody papers? OE ...NO...NA <br /> 13a. Were VOA vials received? YES.. ...NA <br /> b. Was there any observable headspace present in any VOA vial? YES...NO... <br /> 14. Was there a Trip Blank in this cooler? YES... IQ .NA If multiple coolers,sequence# <br /> I certify that 1 unloaded the cooler and answered questions 7-14(initial) <br /> 15a.On pres'd bottles,did pH test strips suggest preservation reached the correct pH level? YES..NO.@ I <br /> b.Did the bottle labels indicate that the correct preservatives were used (?E_jS...N0...NA <br /> 16. was residual chlorine present? YES...NO..<a <br /> I certify that I checked for chlorine and PH as per SOP and answered questions 15-16(initial) <br /> _ I <br /> 17. Were custody papers properly filled out(ink,signed,etc)? E ..NO...NA <br /> 18. Did you sign the custody papers in the appropriate place? YE ...NO...NA <br /> 19. Were correct containers used for the analysis requested? ...NO...NA f <br /> 20. Was sufficient amount of sample sent in each container? ...NO...NA <br /> I certify that I entered this proiect into LIMS and answered questions 17.20(initial) l.1 <br /> 1 I certify that I attached a label with the unique LIMS number to each container(initial) 'l <br /> 21. Were there Non-Conformance issues at login? YES. Was a NCM generated?YES.. 0).# <br /> �J <br /> BIS=Broken in shipment <br /> Cooler Receipt Fonn.doc LF-1 Revised 13.15.15 <br /> End of Form I <br /> Page 49 of 53 4/19/2017 <br />