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TestAmerica <br /> THE LEADER IN ENVIRONMENTAL TESTING <br /> Nashville,TN COOLER RECEIPT FORM <br /> Cooler Received/Opened On 12/9/2011 (a,0800 <br /> 1. Tracking# O) I ,2J (last 4 digits,FedEx) <br /> Courier: FedEx IR Gun ID 14740456 <br /> 2. Temperature of rep.sample or temp blank when opened: <br /> Degrees Celsius <br /> 3. If Item#2 temperature is 0°C or less,was the representative sample or tamp blank frozen? YES NO..40 <br /> 4. Were custody seals on outside of cooler? go-NO...NA <br /> If yes,how many and where: <br /> 5. Were the seals Intact,signed, and dated correctly? fly .,NO...NA <br /> 6. Were custody papers inside cooler? YES..�JO�. .NA <br /> certifvthat I opened the cooler and answered Questions 1-6(Intlall '171", <br /> 7. Were custody seals on containers; YES and Intact YES...NO..(@� <br /> Were these signed and dated correctly? YES...NO...Q I <br /> 8. Packing mat'I used? Bubblewrap PI tic g Peanuts Vermiculite K�Irt Paper Other None <br /> 9. Cooling process: (� Ice-pack Ice(direct contact) Dry ice Other None <br /> 10. Did all containers arrive in good condition(unbroken)? (T§...NO...NA <br /> 11. Were all container labels complete(#,date,signed, pres.,etc)? Ygb...NO...NA <br /> 12. Did all container labels and tags agree with custody papers? 'Y&...NO...NA <br /> 13a. Were VOA vials received? YQ..NO...NA <br /> b. Was there any observable headspace present in any VOA vial? YES.41 ...NA <br /> 14. Was there a Trip Blank in this cooler? YES.QI...NA If multiple coolers,sequence# <br /> 1 certify that I unloaded the cooler and answered auestions 7-14(Intlal) <br /> 15a. On pres'd bottles,did pH test strips suggest preservation reached the correct pH level? YES..NO..140 <br /> b. Did the bottle labels Indicate that the correct preservatives were used Ya..NO...NA <br /> 16. Was residual chlorine present? YES...NO..(jD <br /> certify that I checked for chlorine and PH as per SOP and answered Questions 15-16(intial) <br /> 17. Were custody papers properly filled out(Ink,signed,etc)? X0...NO...NA <br /> 18. Did you sign the custody papers In the appropriate place? AR...NO...NA <br /> 19. Were correct containers used for the analysis requested? Y9...N0...NA <br /> 20. Was sufficient amount of sample sent In each container? 1 F�,..NO...NA <br /> I certify that I entered this protect Into LIMS and answered Questions 17-26(Intial) <br /> I certify that I attached a label with the unique LIMS number to each container(intial) <br /> 21. Were there Non-Conformance Issues at login? YES.(.9 Was a PIPE generated?YES.69.. <br /> BIS=Broken in shipment <br /> Cooler Receipt Form.doc LF-1 Revised 6/24/09 <br /> End of Fonn <br /> Page 45 of 48 12/22/2011 <br />