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CalgonCarbon <br />A Kuraray Company <br />(assigned by laboratory personnel) 80 101877 04 Chain of Cus octy_ <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: 2.02.00 Net Customer Email: <br />Site Address: <br />Analysis Re <br />Sampler Signature 4ie.,__,./ Phone No. Fax No. <br />Special Instructions: Temp "C: uired <br />Sample Remarks / Receipt <br />Number _ <br />Ice:4M o Acceptance Testing i, <br />VI <br />t. <br />4 J <br />tri <br />T1* <br />0 <br />y <br />ti- <br />4C V <br />Sample Disposal El Return to Customer 0 Disposal by Lab <br />No. Sample Identification Date Time No. of Containers Sampling <br />Method <br />Container <br />Type Composite .0 <br />112 o !Glass Plastic 1 2,02.00 AM . ( 2 144) 1 0! Co 1 x X X le) Ow.yS <br />2 202+00 ILI i • 2— Aitiko 16- 60 I )C x X icaq 1. <br />3 2.02.00 PM. 3 Yliko ID: al 1 )( X X LS-pima <br />4 <br />5 <br />6 <br />1a Relin ished . (Signatur Dale <br />A al <br />-7Z024 <br />Time <br />16-4" <br />lb Received by Sig e) Date <br />10120 <br />Time <br />MOO <br />2a Reit , .uishe. .y: (Signature) <br />1 <br />Date <br />2-140.c) <br />Time <br />/SSC) <br />2b Rec ived by: (Signature) <br /> __v " <br />Date Time 3a Relinquished by: (Signature) ate Time 3b Received by: (Signature) Date Time <br />Sample condition upon arrival at laboratory Temp 'C 2,3 Received on ice (circle one)9TN 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: 22003 Tamper Evident Custody Seal Number # <br />WIANI.411•11C L.V1111MIBEI 01111 <br />Laboratory TSR Number <br />20Zooil-Pi