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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 8.00 <br /> 1. Tracking#.�,�(�k (last 4 digits, FedEx) <br /> Courier: FEDEX IR Gun ID 12080142 //1� <br /> 2. Temperature of rep.sample or temp blank when opened: Degrees Celsius <br /> 3. If Item#2 temperature Is 0°C or less,was the representative sample or temp blank frozen? YES.. JD...NA <br /> 4. Were custody seals on outside of cooler? `9...NO...NA <br /> If yes, how many and where: <br /> 5. Were the seals Intact,signed,and dated correctly? ...NO...NA <br /> 6. Were custody papers Inside cooler? O$...NO...NA <br /> I certify that I opened the cooler and answered ouestlons 1-6(Intlal) <br /> i <br /> 7. Were custody seals on containers: YES and Intact YES...NO...Qt, <br /> Were these signed and dated correctly? YES...NO AP I <br /> 8. Packing mat'I used? Bubblewrap PQaAg Peanuts Vermiculite F mms rt Paper Other None <br /> 9. Cooling process: Q� Ice-pack Ice(direct contact) Dry ice Other None <br /> 10. Did all containers arrive in good condition(unbroken)? 'Q...NO...NA <br /> 11. Were all container labels complete(#,date,signed,pres.,etc)? ' C' ...NO...NA <br /> 12. Did all container labels and tags agree with custody papers? 1�,S...NO...NA <br /> 13a. Were VOA vials received? NO..NO...NA <br /> b. Was there any observable headspace present in any VOA vial? YES..DSI ...NA <br /> 14. Was there a Trip Blank In this cooler? YES...0...NA If multiple coolers,sequence# <br /> certify that I unloaded the cooler and answered questions 7-14(Intal) <br /> 15a. On pres'd bottles,did pH test strips suggest preservation reached the correct pH level? YES...NO... <br /> � <br /> In. Did the bottle labels Indicate that the correct preservatives were used % :..NO...NA <br /> 16. Was residual chlorine present? YES...NO.. A <br /> I certifvthat I checked for chlorine and pH as per SOP and answered ouestions 15-16 flntial) <br /> 17. Were custody papers properly filled out(Ink,signed,etc)? `Kg-)..NO...NA <br /> 18. Did you sign the custody papers In the appropriate place? Y�..NO...NA <br /> 19. Were correct containers used for the analysis requested? Ya..NO...NA <br /> 20. Was sufficient amount of sample sent In each container? u...NO...NA <br /> I certify that I entered this Prolect Into LIMS and answered questions 17-20(Intlal) G� <br /> 1 certify that I attached a label with the unique LIMS number to <br /> each container(intlal) <br /> 21. Were there Non-Conformance Issues at login? YES...Nt1L Was a PIPE generated?YES..1$Ax..# <br /> HIS=Broken in shipment <br /> Cooler Receipt Form.doc LF-1 Revised 6/24/09 <br /> End ofForm <br /> Page 46 of 48 12/22/2011 <br />