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r . <br /> r <br /> TestAmerl,.4-1 <br /> Nashville Division <br /> r COOLER RECEIPT FORM BC# <br /> 390325 <br /> Client Name • <br /> Cooler Received/Opened On: 9123104 Accessi0 ed By:� Shawn GraceY_ <br /> Log-in Personnel Signature <br /> 1. Temperature of Cooler when triaged: Degrees Celsius <br /> 2 Were custody seals on outside of cooler9 /YES„!N0 NA <br /> r �� <br /> a. If yes,how many,what kind and where <br /> '14- <br /> 3 Were custody seals on containers and intacY� YES NA <br /> 4. Were the seals intact,signed,and dated correctly NO NA <br /> 5 Were custody papers inside cooler' . YE NO NA <br /> I <br /> G Were custody papers properly filled out(Ink,signed,etc)? YES NO NA <br /> 7 Did you sign the custody papers in the appropriate places .. YES NO NA <br /> 8 What kind of packing material used% Bubblewrap Peanuts Vermiculite Othe Nyn� <br /> 9 Cooling process v, cep Ice-pack Ice(direct contact) Dry ice Other None <br /> 10 Did all containers arrive in good condition(unbroken)? dNO <br /> NO NA <br /> I11 Were all container labels complete(#,date,signed,pres,etc)' NA <br /> 12 Did all container labels and tags agree with custody papers9 YE5 NO NA <br /> 13 Were correct containers used for the analysis requested9 YES NO NA <br /> 14 a. Were VOA vials received' YES STA <br /> I <br /> b Was there any observable head space present in any VOA vial' NO YES .PCNA) <br /> 15 Was sufficient amount of sample sent in each container9 YES NO NA <br /> 16 Were correct preservatives used9 YES NO <br /> If not,record standard ID of preservative used here C <br /> 17 Was residual chlorine present9 NO YES <br /> I <br /> 18 Indicate the Airbill Tracking Number(last 4 digits for Fedex only)and Name of Courier below j <br /> Fe - UPS Velocity Airborne Route Off-street Mise � <br /> 19 If allon-Conformance exists,see attached or comments below. <br /> I <br /> 1 <br /> ('nnler Recerot Form <br /> -1 Revised 313/04 <br />