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' TEST AMERICA ANALYTICAL <br />' TESTING CORP.-NASfWILLE <br /> • COOLER RECEIPT FORM BC# <br /> Iy <br /> /l.� 324439 <br /> �r <br /> Client — 1 1 <br />' Cooler Received On. 3/19/03 And Opened On 3/19/03 By: Ben Wright <br /> Prg'tgnature <br /> 1 Temperature of Cooler when opened 4 n Degrees Celsius <br />' 2 Were custody seals on outside of cooler' .. . . YES • NA <br />' a If yes,how many, what kind and where fZlz <br /> 3 Were custody seals on containers and intact° . . . . . . . ... .. ..NO . YES <br />' 4 Were the seals intact, signed, and dated correctly9.. . .. .YES NOTRA <br /> 5 Were custody papers inside cooler`' .. .... . . NO NA <br />' 6 Were custody papers properly filled out (ink si ned,etc ? , NO NA <br />' • 7 Did you sign the custody papers in the appropriate place?. �- S .NO . NA <br /> 8 What land of packing material used ewra aunts Vermicuhte Other None <br /> I9 Was sufficient ice used (if appropriate) . .. .. . . . NO NA <br /> 10 Did all bottles arrive in good coudition( unbroken)? . . YE NO NA <br />' 11 Were all bottle labels ##,date, ned, res,etc) <br /> complete si , .. S NO NA <br /> P ( g P <br />' 12 Did all bottle labels and tags agree with custody papers' . �Y�5 NO NA <br /> l <br /> 13 Were correct bottles used for the analysis reguested9 . .. NO NA <br /> I ... 1 <br /> 14. a Were VOA vials received' Y S NO. NA <br /> b Was there any observable head space present in any VOA vial? �.�T^ . .YES NA <br /> I 15 Was sufcieut amount of sum le sent�n each bottle? . . . �` NO NA <br /> P YE <br /> I 16 Were correct preservatives used? . .. . _ YE NO NA <br /> If not, record standard ID of preservative used here <br />' 17 Was residual chlorine present9 . . NO. YES <br /> 18. See attached for resolution of non-conformance <br /> Fed-Exp UPS Velocity Airborne Route Off-street Mise. <br />' Cooler Receipt Form LF-1 316103 <br />