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TestAmer.-A <br /> ANAII'TICAL TESTING CORPORATION <br /> Nashville Division <br /> COOLER RECEIPT FORM BC# <br /> ' 390494 <br /> � r <br /> Client Name <br />' CooIer Received/Opened On: 9124104 Accession By: Shawn Grace <br />' Log-in P rsonnel Signature <br /> I Temperature of Cooler when triaged: Degrees Celsius <br />' 2 Were custody seals on outside of cooler9 YES .NO NA <br />' a If yes,how many,what kind and where �A <br /> 3 Were custody seals on containers and intact9. VN0 <br /> ES NA <br />' 4. Were the seals intact,signed,and dated correctly? NA <br /> 5 Were custody papers inside cooler' ( YE51 .NO NA <br /> 5 Were custody papers properly filled out(ink,signed,etc) M .N0 <br /> NO NA <br /> 7 Did you sign the custody papers in the appropriate place9 NA <br /> 8 What kind of packing material use ubbl Peanuts Vermiculite Other None <br /> 9 Cooling process ce Ice-pack Ice(direct contact) Dry ice Other None <br /> 10 Did all containers arrive in good condition(unbroken)9 . dNO <br /> NO NA <br /> 11 Were all container labels complete(#,date,signed,pres,etc)? NA <br />' 12 Did all container labels and tags agree with custody papers?. .. YE5 NO NA <br /> 13. Were correct containers used for the analysis requested9 YES NO NA <br />' 14. a Were VOA vials received9 YES (NO .SIA <br /> b Was there any observable head space present in any VOA vial'' NO YES NA <br />' 15 Was sufficient amount of sample sent in each container? YES NO NA <br /> 15 Were correct preservatives used? YES NO U <br />' If not,record standard ID of preservative used here <br /> 17 Was residual chlorine present" NO YES NA <br /> 18 Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below <br /> O <br /> ed-E UPS Velocity Airborne Route Off-street Misc. <br />' 19 If a Non-Conformance exists,see attached or comments below <br /> ICooler Receipt Form LF-1 Revised 313104 <br /> End of Form <br />