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' <br />faAss <br />22003 Additional sample remarks: Tamper Evident Custody Seal Number # <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 />180 101877 04 Chain of Cus ody (assigned by laboratory personnel) <br />CalgonCarbon <br />A Kuraray Company <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: 2.02.00 Net Customer Email: <br />Site Address: <br />Sampler Signature <br />/ <br />,l_., _ III Phone No. 1 Fax No. <br />Special Instructions: Temp "C: Analysis Re . uired <br />Sample Remarks / Receipt <br />Number <br />Icelo Acceptance Testing —1E <br />N. <br />VI <br />1a/ J rn <br />tt <br />.f. <br />ti <br />tt <br />< cl <br />Sample Disposal 0 Return to Customer O Disposal by Lab <br />No. Sample Identification Date Time No. of Containers Sampling <br />Method <br />Container <br />Type Composite .0 <br />El' cD Glass Plastic 1 2.02.60 Al Ct - I 2 /44.0 10:06 i x X X io DA.ys <br />2 2-02.00 iil 9•2- 7-14ilzb io.. op I )C X X /5D.q41- <br />3 <br />4 <br />2.02•00 PICT .3 2k° WO I ›C X X <br />5 <br />6 <br />la Relin ished - (Signatur Daie <br />i li 1 <br />7Z026 <br />Time <br />16.4"4 <br />lb Received by i Sig re Date <br />ate bazf's <br />Time 2a Re)) uished y: (Signature) Date <br />2111 <br />Time <br />iSSC) <br />2b Rec ived by: (Signature) 1 Date Time <br />IS-5 0 <br />3a Relinquished by: (Signature) Time 3b 3b Received by: (Signature) Date Time <br />Sample condition upon arrival at laboratory Temp 'C 2,3 Received on ice (Circle One)('-'17 - N Sample intact and acceptable for evaluation? (Circle One)(/ N <br />Initials of personnel checking in sample: .---z '2_, I. Sample disposed of by: (signature) Date: jo 17 1, e5ed Laboratory TSR Number <br />20Zoollict