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' TE S TAMERICA <br /> ,INC.-NASHVILL7E <br /> COOLER RECEIPT FORM <br />' Client BC#^2'1 Soij <br />' Cooler Received On. 3 S,oz- And Opened On- 3 9 ,>2- By; Claris Wilmoth <br /> Cy� <br />' (Signature) <br /> 1 Tempei atui e of Cooler when opened_ G Degrees Celsius _ <br />' 2 Were custody seals on outside of cooler, i NO <br /> a. If yes, how many, what kind and where <br /> 3 Were custody seals on containers and intact9 NO YES <br /> 4 Were the seals intact, signed, and dated correctly9 .NO <br /> 1 <br /> a Were custody papers inside cooler? NO <br />' 6 Were custody papers properly filed out (ink,signed,etc)A (!§...NO <br /> �5 7 Did you sign the custody papers in the appropriate place9 .. ISS NO <br /> 1 r <br /> 8 What kind of packing material used? ubbiewr Peanuts Vermiculite Other None <br />' 9 Was sufficient ice used (if appropriate)? .. . , , ,C& NO <br /> lJti� .��r <br /> 10 Did all bottles arrive in good condition( unbroken)? .,... YES NO Mw-4 <br /> lI Were all bottle labels complete (#,date,signed,pres,etc)?. .. cn§ NO <br /> 12 Did all bottle labels and tags agree with custody papers? NO <br />' 13 Were correct bottles used for the analysis requested9.. . .. .. . NO <br />' 14. a, Were VOA vials received9 . . .. NO <br /> b. Was there any observable head space present in any VOA vial9 � YES <br />' 15 Was sufficient amount of sample sent in each bottle9 + NO <br /> 16 Wei e correct preservatives used9 � NO <br />' 17 Was residual chlorine present9 NO YES <br />' 18 Corrective action taken, if necessary <br /> �} See attached for resolution <br />' Cooler Receipt Form LF-1 9/12/00 <br />