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(assigned by laboratory personnel) 180 101877 04 Chain of Cus ody <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 />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: 2.0 ZOO PM Customer Email: <br />Site Address: <br />Sampler Signature <br />/ <br />Phone No. Fax No. <br />Special Instructions: Temp "C: Analysis Re . uired <br />Sample Remarks / Receipt <br />Number <br />Ice'4051 o Acceptance Testing i <br />k. <br />kil <br />4 -I rn <br />II. <br />0 <br />9 <br />"- <br />4c <br />V <br />Sample Disposal 0 Return to Customer (.1 Disposal by Lab <br />No. Sample Identification Date Time No. of Containers Sampling <br />Method <br />Container <br />Type Composite .0 <br />E. 0 Glass Plastic 1 Zolboiqq. I i A i ke, ao! 00 1 X X X It) 0".ys <br />2 202,00 lq i • Z— 214.1/20 16 OD I )C X X icp.q..0 <br />LS" - Yr 3 2.0240 Pil • 3 77 /1ij20 IMO I )( X x <br />4 <br />5 <br />_ <br />6 <br />la Relin ished • (Signatur Dale <br />a. ij I <br />-11Z0Z6 <br />Time <br />16-4:4 <br />lb Received by Sig re) Date <br />a le <br /> <br /> <br />lime <br />moo <br />2a Re)) uished y: (Signature) <br />ty <br />Date <br />2.41m) <br />Time <br />issc.) <br />2b Rec ived by: (Signature) <br />'77 L--, ......„------- <br />Date <br />-21`11 1,0 <br />lime <br />IC •N 6 <br />3a Relinquished by: (Signature) Time 3b Received by: (Signature) Date Time <br />Sample condition upon arrival at laboratory Temp 'C 2 , 3 Received on ice (Circle One)c.i . N Sample intact and acceptable for evaluation? (Circle Onerl N <br />2.. L Initials of personnel checking in sample: '.7 Sample disposed of by: (signature) Date: <br /> - IVAN IC 131 1102.11.31 ZAI1IMW.:77 1 O4O6 86ed Laboratory TSR Number <br />2ozoomici