Laserfiche WebLink
Laboratory TSR Number Carbon Acceptance Number (CAN) <br />(assigned by laboratory personnel) <br />IN( <br />CHAIN OF CUSTODY RECORD <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 />SUBMITTED FOR ANALYSIS IN ORDER FOR SAMPLE TO BE ACCEPTABLE FOR EVALUATION** <br />Customer Name: Dotio 14c5Y):::. SC21 t.),...m..., LLC-- Customer Email: <br />_ <br />Site Address: eiaL L 0./2- a.; et 0-e, ricA eP A-.\-s‘pv,(3 OLkScS-- 014"4.1-4-101" <br />Sampler Signature Phone No. Fax No. <br />Special Instructions: Temp °C: Analysis Required <br />Sample Remarks / Receipt <br />Number <br />lc No <br />Ce <br />a <br />*.r.. cr) a) <br />I— <br />cl) u c to <br />a. a) c) o <br />< <br />Sample Disposal 0 Return to Customer El Disposal by Lab <br />No. Sample Identification Date Time No. of Containers Sampling <br />Method <br />Container <br />Type Composite sa <br />E <br />0 <br />"' 0 (13 Plastic 1 D5M N( )2.5_16 3 i; sr <br />2 <br />3 <br />4 _ _ <br />5 <br />6 <br />la Relinquished <br />,,0-12#2,01-7i <br />by: (Signature) Date <br />l 6141 <br />Time <br />/ ! s -5- <br />lb Received by: (Signature) Date Time 2a Relinquished by: (Signature) Date lime <br />2 b ec e : (Signature) rye <br />/14/zo <br />Time 32 Relinquished by: (Signature) Date Time 3b Received by: (Signature) Date lime <br />Sample condition upon arrival at laboratory Temp 9C ziy Received on ice (Gird° One Sample Sample intact and acceptable for evaluation? (Cirde One) OP N <br />Initials of personnel checking in sample: Mmf Sample disposed of by: (signature) Date: <br />Additional sample remarks: <br />V <br />.e cI c, C J-'— f\ C' Cooker 2 vC <br />Tamper Evident Custody Seal Number # •