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i <br /> TESTAMERICA INC.-NASHVILLE <br />' COOLER RECEIPT FORM <br /> Client <br /> Cooler Received On d Opened On /aLAZP ri <br /> • Ben Wht <br /> 1C <br /> (Signature) <br />' 1 Temperature of Cooler when opened Degrees Celsius <br /> 2 Were custody seals on outside of cooler9 YES NIA <br />' a If yes, how many,what land and where- <br /> b Were the seals intact,signed,and dated correctly9 YES NO <br /> y <br /> 3 Were custody seals on containers and intact?. . ... ......... ... ........ . YES NIA <br /> 4 Were custody papers inside cooler? .. . ..... .. NO NIA <br /> 5 Were custody papers properly filled out(iak,srgned,etc)? , . NO NIA <br />' . 6 Did you sign the custody papers in the appropriate place9 NO NIA <br /> 7 What land of paclang material used? u ewrap eanuts Vermiculite Other None <br />' g Was sufficient ice used (if appropriate)? .., , „ . NO NIA <br /> 9, Did all bottles arrive in good condition( unbroken)?.�, .(tJi8 NO NIA <br />' Io Were aff bottle labels complete (#,date,signed,pres,etc)? . NO NIA <br /> 11. Did all bottle labels and tags agree with custody papers?. .. <5 NO NIA <br /> I <br /> 1Z. Were correct battier used for the analysis requested?. .. . .. NO NIA <br />' 13. a. Were VOA vials received?.. ..... .......... ..... .. ... .. .. . &P3 <br /> NO NIA <br /> b Was there any observable head space present in any VOA vial9.. YES NIA <br />' 14 Was sufficient amount of sample sent in each bottle? NO NIA <br /> 15 Were correct preservatives used9 . _(NO N/A <br /> If not, record standard ID of preservative used here <br /> 16 Was residual chlorine present". .. . .. .. .. .. . .NO YES IA <br /> 17 Corrective action taken,if necessary <br /> .` See attached for resolution <br />' <br /> cooler Receipt Form <br /> LF-1 9/17/02 <br />