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TESTAMERICA, INC. <br /> COOLER RECEIPT FORM <br /> Client -F JC_ BC# 7� <br /> ICooler Received On ff <icL And Opened n F����(�` By Mark Beasley J � <br /> (Sfgnat rey <br /> 1 Temperature of Cooler when opened -' DEGREES CELSIUS <br /> 2 Were custody seals on outside of cooler and intact? . . YES NO <br /> a If yes,what kind and where TAPE I <br /> b Were the signature and date correct? . ... .... ... NO <br /> 3 Were custody seals on containers intact? . . . ....................... . NO <br /> 4. Were custody papers inside cooler? ................. . . .YES NO , <br /> 5 Were custody papers properly filled out(ink,signed,etc)? . . ... � NO <br /> 6 Did you sign the custody papers in the appropriate place? =-YE—S--NO <br /> 7. What land of packing material was us ? Bubblewrap P anuts Other None <br /> 8 Was sufficient ice used (if appropriate)?....... .. . . . . . ..,. .1v0 <br /> 9 Did all bottles arrive in good condition(unbroken)? .. . . . . ....... �NO <br />' 10 Were all bottle labels complete (#,date,signed,pres,etc)?. .,. ........ C.. YE'� NO <br /> 11. Did all bottle IabeIs and tags agree with custody papers?... . . .. . . ....... �.Y NO <br />' 12. Were correct bottles used for the analysis requested? . ... . . ..YES NO <br /> 13. If present, was any observable VOA headspace present?................... ... .... .... NO <br />' 14. If present,were VOA vials checked for absence of air bubbles and noted if found9 . ... ..YES O <br /> 15 Was sufficient amount of sample sent in each bottle? ... ... .. .. .... YF NO <br /> 16. Were correct preservatives used?......... .. . . . ... . .... .. . ..YES NO <br />' 17. Was residual chlorine present(if appropriate?).. ......... . ...... ..... <br /> ...... .. YE NO <br /> 18. Corrective action taken, if necessary <br /> a Name of person contacted. SEE ATTACKED FOR RESOLUTION IF NEEDED <br /> b Date; <br /> Cooler Receipt form LF-1 1018199 <br />