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i <br /> Test medca <br /> THE LEADER IN ENVIRONMENTAL TESTING <br /> Nashville,TN COOLER RECEIPT FORM <br /> 720-78845 Chain of Custody <br /> Cooler Received/Opened On 4/12/2017 1015 <br /> l Z� �l iz/I-) <br /> Time Samples Removed From ooler ` me Samples Placed In Storage ?JZ (2 Hour Window) <br /> 1. Tracking#j�rov�f (last 4 di its FedEx) Courier: _FedE1x_, <br /> IR Gun ID_160406069_ pH Strip Lot I\j 1 j Chlorine Strip Lot A <br /> 2, Temperature of rep.sample or temp blank when opened:2-16 Degrees Celsius <br /> 3. If Item#2 temperatures is 0°C or less,was the representative sample or temp blank frozen? YES NO..QJA <br /> 4. Were custody seals on outside of cooler? YES. .NO...NA <br /> If yes, how many and where: l <br /> 5. Were the seals intact,signed,and dated correctly? Y` E�S...NO...NA <br /> 6. Were custody papers inside cooler? DYE .NO...NA j <br /> P` <br /> certify that I opened the cooler and answered questions 1-6(initial) <br /> 7. Were custody seals on containers: YESt O and Intact YES...NO.6 <br /> i <br /> Were these signed and rectly? YES...NO.. <br /> 8. Packing mat'I used Bubblewr Plastic bag Peanuts Vermiculite Foam Insert Paper Other None <br /> i <br /> 9. Cooling process: Ice Ice-pack Ice(direct contact) Dry ice Other None <br /> 10. Did all containers arrive in good condition(unbroken)? reES <br /> .NO...NA <br /> 11. Were all container labels complete(#,date,signed, pres.,etc)? .NO. <br /> 12. Did all container labels and tags agree with custody papers? &E ...NO...NA/. <br /> 13a. Were VOA vials received? ��YEES. Iq..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... 10 .NA If multiple coolers,sequence# <br /> I certify that I unloaded the cooler and answered questions 7-14(initial) <br /> 1� <br /> 15a.On pres'd bottles,did pH test strips suggest preservation reached the correct pH level? YES.. %O ) <br /> b.Did the bottle labels indicate that the correct preservatives were used �..NO...NA <br /> 16. was residual chlorine present? YES...NO.. I0 <br /> I certify that I checked for chlorine and pH as per SOP and answered questions 15-16(initial) - <br /> 17. Were custody papers properly filled out(ink,signed,etc)? ...NO...NA <br /> 18. Did you sign the custody papers in the appropriate place? ...NO...NA <br /> 19. Were correct containers used for the analysis requested? 4!0..NO...NA <br /> 20. Was sufficient amount of sample sent in each container? ES ..N0...NA <br /> Lvl <br /> I certify that I entered this proiect into LIMS and answered questions 17-20(initial) " <br /> I( <br /> certify that I attached a label with the unique LIMS number to each container(initial) <br /> 21. Were there Non-Conformance issues at login? YES..fNO )Was a NCM generated?YES. ..# <br /> `0 I; <br /> 1 <br /> BIS=Broken in shipment <br /> Cooler Receipt Fonn.doc LF-1 Revised 12/15/15 <br /> End of Fonn j <br /> Page 48 of 52 4/18/2017 i <br />