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FT—estAmerica <br /> ANALYTIGt TESTING[ORPORAAON <br /> Nashville Division <br /> COOLER RECEIPT FORM BC# M913 <br /> Client Name ETIC Engineering <br /> Cooler Received/Opened On: 3129105 Accessioned By: James D. Jacobs <br /> QEk2L." <br /> Logan PertqfiWigniture <br /> 1. Temperature of Cooler when triaged: Degrees Celsius <br /> 2 Were custody seals on outside of cooler9 . /1'ES! NO NA <br />' a. If yes,how many and where rrR <br /> 3 Were custody seals on containers? / 0 YES NA <br /> 4. Were the seals intact,signed,and dated correctlyry IDS <br /> NO NA <br /> 5 Were custody papers inside cooler" NO NA <br /> 6 Were custody papers properly filled out(ink,signed,etc)9 (9E NO NA <br /> 7 Did yon sign the custody papers in the appropriate place? ES NO NA <br /> lie ' <br /> 8 What kind of packing material used' bblewrap <br /> uPeanuts Vermiculite Other None <br /> 9 Cooling process ice Ice-pack Ice(direct contact) Dry ice Other None <br /> 10 Did all containers arrive in good condition(unbroken)? - E NO NA <br /> 11 Were all container labels complete(#,date,signed,pres,etc)7 ES NO NA <br /> 12 Did all container labels and tags agree with custody papers9 E NO NA <br /> 13 Were correct containers used for the analysis requested? 'ES NO NA <br /> 14 a Were VOA vials received9 . (9 NO NA <br />' b Was there any observable head space present in any VOA vials YES NA <br /> 15 Was sufficient amount of sample sent in each container? E . NO NA <br /> 16 Were correct preservatives used? YES . NO NA <br /> If not,record standard ID of preservative used here <br /> 17 Was residual chlorine present? NO YES <br /> 18. Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below �1J <br /> 7023 <br /> ed- UPS Velocity DHI. Route Off-street Mist <br /> 19.If a Non-Conformance exists,see attached or comments below <br />' Cooler Receipt Form LF-1 Revised 1219!04 <br /> End of Form <br />