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1 <br /> TestAmeri:01 <br /> Nashville Division <br /> COOLER RECEIPT FORM BC# <br /> 391449 <br /> IClient Name ETIC Engineering <br /> Cooler Received/Opened On: 1011104 Accessioned By: James D. Jacobs <br /> rYQ?A1__-q <br /> Log-in Peso el Signature <br /> 1. Temperature of Cooler when triaged Degrees Celsius <br /> 2 Were custody seals on outside of cooler? .. .. (!� NO NA <br /> a If yes,bow many,what kind and where E,,,,rii <br /> 3 Were custody seals on containers and mtact9 .. . NO YES NA <br /> 4 Were the seals intact,signed,and dated correctly' 09 <br /> NO NA <br /> 5 Were custody papers inside cooler' YE NO NA <br /> 6 Were custody papers properly filled out(ink,signed,etc)'' . . E NO NA <br /> 7 Did you sign the custody papers in the appropriate place9 NO NA <br /> 8 What kind of packing material used9 Bubblew p Peanuts Vermiculite Other None <br /> 9 Cooling process Ice Ice-pack Ice(direct contact) Dry ice Other None <br /> 10 Did all containers arrive in good condition(unbroken)9 .. YE NO NA <br /> 11 Were all container labels complete(#,date,signed,pres.,etc)? NO NA <br /> 12 Did all container labels and tags agree with custody papers9 1'E NO NA <br /> . <br /> 13 Were correct containers used for the analysis requested' E .NO NA <br /> 14 a. Were VOA vials received9 'E NO NA <br /> b Was there any observable head space present in any VOA via19 NO YES NA <br /> 15 Was sufficient amount of sample sent in each container' (9 NO NA <br /> 16 Were correct preservatives used ( ESyNO NA <br /> If not,record standard ID of preservative used here `J <br /> 17 Was residual chlorine present9 NO YES NA <br /> 18 Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below <br />' 7334 <br /> e 33 UPS Velocity Airborne Route Off-street Misc <br /> ' 19 If a Non-Conformance exists,see attached or comments below <br /> iCooler Receipt Form LF-1 Revised 313104 <br /> End of Form <br />