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Test America <br /> ANALYTICAL TESTING CORPORATION <br /> Nashville Division <br />' COOLER RECEIPT FORM BC# <br /> 366373 <br />' Client Name <br /> Cooler Received/Opened On. 3/04/04 Accessioned By-_Shawn Gracev <br /> Log-in ersonnel Signature <br /> 1 Temperature of Cooler when triaged Degrees Degrees Celsius <br /> 2 Were custody seals on outside of cooler? z NO NA <br /> a If ves, how many,what land and where z <br /> t3 Were custody seals on containers and intact' YES NA <br /> 4 Were the seals intact,signed, and dated correctly' NO NA <br /> 5 Were custody papers inside cooler? )9 NO NA <br /> 6 Were custody papers properly filled out(ink,signed,etc)' '�G NO NA <br /> i7 Did you sign the custody papers in the appropriate place' ES NO NA <br /> 8 What kind of packing material used' blewrap Peanuts Vermiculite Other None <br /> 9 Cooling process L5P <br /> Ice-pack ce(direct contact) Dry ice Other None <br /> IQ Did all containers arrive in good condition(unbroken)' NO NA <br /> 11 Were all container labels complete(#, date,signed pres,etc)' SNO <br /> NO NA <br /> 12 Did all container labels and tags agree with custody papers'' NA <br /> 13 Were correct containers used for the analysis requested? 74; 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 container' NO NA <br /> 16 Were correct preservatives used' S NO NA <br /> If not, record standard ID of preservative used here <br /> 17 Was residual chlorine present' NO YE N <br />' 18 Indicate the Aarbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below <br /> UPS Velocity 4irborne Route Off-street M>sc <br /> 19 Iffaa Non-Conformance exists,see attached or comments below <br /> ' C,.pier RCLL,pt l-orm Lf- <br />