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i <br /> TestAmen' ,.a <br /> ANALYTICAL TESTING CORPORATION <br /> Nashville Division <br /> I COOLER RECEIPT FORM BC# <br /> 380488 <br /> Client Name : <br /> Cooler Received/0 ened On: 9124104 Accessioned B : Shawn Grace <br /> Received/Opened y <br /> �-. <br /> 1 Log-in Personnel Signature <br /> 1. Temperature of Cooler when triaged: LrDegrees Celsius <br /> 2 Were custody seals on outside of cooler9 . l YES NO NA <br /> a If yes,how many,what kind and where <br /> 3 Were custody seals on containers and intact' V 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 />' 6 Were custody papers properly filled out(mk,signed,etc)9 YES NO. NA <br /> 7 Did you sign the custody papers in the appropriate place9 YE5 NO NA <br /> I8 What kind of packing material use Bubblew eauuts 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 YE5 NO NA <br />' 11 Were all container labels complete(#,date,signed,pres,etc)' E NO . 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 requested' YES NO NA <br /> 14 a Were VOA vials received' YES A <br /> b Was there any observable head space present in any VOA vial" NO YES ) <br /> 15. Was sufficient amount of sample sent in each container' YES NO NA <br /> 16 Were correct preservatives used' YES NO <br />' If not,record standard ID of preservative used here <br /> 17 Was residual chlorine present9 NO YES �IYA <br />' 18 Indicate the Airbill'Tracking Number(last 4 digits for Fedex only)and Name of Courier below <br /> ed- UPS Velocity Airborne Route Off-street Misc <br />' 19 If a Non-Conformance exists,see attached or comments below <br />' Cooler Receipt Form LF-i Revised 3/3/04 <br /> End of Form <br />