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TestAmerica <br /> ANALYTfCAC 7E5TING CORPORA710N <br /> Nashville Division <br /> COOLER RECEIPT FORM BC# 11 11 111111 IN I 111111 111111 11 <br /> 357192 <br /> 7 J <br /> Client G l�L--� G /4�l/ 7,, w-, -11j <br /> Cooler Received On- 12-10-03 And Opened On: 12-10-r03 By:MARVIN 13LUMHOEFER <br /> ���/Ah <br /> (Signature) tl <br /> 1 Temperature of Cooler when opened Degrees Celsius <br />' 2 Were custody seals on outside of cooler' . . . . . . . . . . . NO .. NA <br /> a If yes, how many, what kind and where Lai <br /> 3. Were custodyseals <br /> on <br /> containers and intact9. . . . . . . . . . .N YES. NA <br /> 4 Were the seals Intact, signed, and dated correctly? . . .... .. .YES NO (<A' <br /> 5 Were custody papers inside cooler?. . . . . . .. .. . ... .. .. NO . NA <br /> 6 Were custody papers properly filled out(ink,signed,etc)'. . NO NA <br /> 7 Did you sign the custody papers in the appropriate place? . .. ..... .YE .NO .NA <br /> S. What kind of packing material used CBubb1eW_r`ap- Peanuts Vermiculite Other None C-le; rare <br /> 9 Cooling process Cce Ice pack Ice(direct contact) Dry Ice Other None ` ! <br /> 10 Did all containers arrive in good condition( unbroken) .. . . .... , Us NA <br /> IS <br /> 74v <br /> 11 Were all container labels complete (#,date,signed,pres,etc)9 . . . . . . . . . `S NO NA <br /> � <br /> 12 Did all container labels and tags agree with custody papers' .. .. NO NA <br /> 13 Were correct containers used for theT <br /> analysis requested . . .,NO NA <br /> 14 a Were VOA vials received? ., . . NO NA <br /> b Was there any observable head space present in any VOA vial9 .YES.. NA <br /> 15 Was sufficient amount of sample sent in each container' .. . . . . S ' NO <br /> NA <br /> 16 Were correct preservatives used? ., , . . . . . . .. . , NO NA <br /> If not, record standard ID of preservative used here vj <br /> 17 Was residual chlorine present? .. ... �` <br /> . NO .YES. N� <br /> 18 attached for resolution of non-conformance- <br /> Fed-Ex UPS Velocit} Airborne Route Ott-street Mise <br /> � I <br /> Cooter Rc f-eint f of n LI-I 9/3/03 <br /> End of Fo3rn <br />