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TestAmerica <br /> ANALYTICAL TESTING CORP0R,4710N <br /> Nashville Division <br /> COOLER RECEIPT FORM BC# <br /> 366990 <br /> Client Name ETIC ENGINEERING <br /> Cooler Received/Opened On. 3/9/04 Accessioned By Shawn Gracev <br /> Log-, Personnel Si ature <br /> 1 Temperature of Cooler when triaged /i Degrees Celsius <br /> 2 Were custody seals on outside of cooler" NO NA <br /> a If yes,how many,what kind and where <br />' 3 Were custody seals on containers and intact9 YES NA <br /> 4 Were the seals intact,signed,and dated correctly? E NO NA <br /> 5 Were custody papers inside cooier9 'E NO NA <br /> 6 Were custody papers properly filled out(ink,signed,etc)9 NO NA <br /> 7 Did you sign the custody papers in the appropr lace? E NO NA <br /> 8 What land of packing materiak used' B blewr Peanuts Vermiculite Other None <br /> 9 Cooling process 5) Ice-pack Ice(direct contact) Dry ice Other None <br /> 14 Did all containers arrive in good condition(unbroken)9 6P NO NA <br /> 11 Were all container labels complete(#,date,signed,pres,etc)' `/JYES/NO NA <br /> 12 Did all container labels and tags agree with custody papers9 NO NA <br /> 13 Were correct containers used for the analysis requested' S NO NA <br /> 14 a Were VOA vials received? 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 contamer9 E NO NA <br /> I6 Were correct preservatives used? YE NO NA <br /> If not, record standard ID of preservative used here <br /> 17 Was residual chlorine present? NO YES NA <br /> 18 Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below <br /> ed- UPS Velocity Airborne Route Off-street Mise <br /> 19 If a Non-Conformance exists,see attached or comments below <br /> Cooler Receipt Form LF-1 Revised 313!04 <br /> End of Form <br />