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Laboratory TSR Number <br />2ozoo/Licr <br />(assigned by laboratory personnel) _ 80 101877 04 Chain of Cus ody <br />CalgonCarbon <br />A Kuraray Company <br />CALGON CARBON CORPORATION <br />Carbon Acceptance Laboratory <br />Mailing Address: P.O. Box 717, Pittsburgh, PA 15230-0717 <br />Sample Shipping Address: 3000 GSK Drive, Moon Township, PA 15108 <br />Phone (412) 787-6700 • Fax: (412) 787-4795 <br />CHAIN OF CUSTODY RECORD <br />**THIS COMPLETED FORM MUST ACCOMPANY ALL SAMPLES SUBMITTED FOR ANALYSIS IN ORDER FOR SAMPLE TO BE ACCEPTABLE FOR EVALUATION** <br />Customer Name: Zo Zoo lii q Customer Email: <br />Site Address: <br />Sampler Signature 1/41Ct/ Phone No. 1 Fax No. <br />Special Instructions: Temp "C: Analysis Re uired <br />Sample Remarks / Receipt <br />Number <br />Ice .401511 <br />a) C 7.. (11 a) I— <br />a) u <br />0. cy k <br />—1 <br />1%71 <br />I" <br />T <br />9 <br />".. <br />$ <br />Sample Disposal Li Return to Customer [II Disposal by Lab <br />No. Sample Identification Date Time No. of Containers Sampling <br />Method <br />Container <br />Type Composite .o Glass C) <br />1 ZDZoollict. I 2 /q/ Zb io. oo ' 1 - X X x le) Da.y.S <br />2 7-02.00 iq 9 . 2- 2/q/zo 16,60 I )C x X <br />3 <br />4 <br />2.021,0 NI • 3 7/q/20 mob I, X' X X i5 <br />5 <br />6 <br />la Relin. shed . (Signatur- <br />A 1 / 4111 <br />Date <br />J. ,, / <br />7Z024 <br />Time <br />16-4:. <br />lb Received by. Sig e) Date <br />ate /164) <br />Time <br />00 <br />Ti <br />I <br />m <br />Lei <br />2a Reli..uishe. .y (Signature) <br />If <br />Date <br />21416 <br />Time <br />ISSC.) <br />2b Rec•ived by: (Signature) Date Time 3a Relinquished by: (Signature) 3b Received by: (Signature) Date Time <br />Sample condition upon arrival at laboratory Temp 'C 2 ,3 Received on ice (Circle Orre.)(7- N Sample intact and acceptable for evaluation? (Circle One// N <br />Initials of personnel checking in sample: .7 Sample disposed of by: (Signature) Date: <br />Additional sample remarks: Tamper Evident Custody Seal Number # 22003 <br /> OZ lo 61. a5ed *.imivrzArta k',JenC.1M --El-