COTDEDFCB (2) - Laserfiche WebLink

Home Browse Search

II (assigned by laboratory personnel) CalgonCarbon A Kuraray Company 80 101877-04 Chain of Custody CALGON CARBON CORPORATION Carbon Acceptance Laboratory Mailing Address: P.O. Box 717, Pittsburgh, PA 15230-0717 Sample Shipping Address: 3000 GSK Drive, Moon Township, PA 15108 Phone (412) 787-6700 • Fax: (412) 787-4795 CHAIN OF CUSTODY RECORD **THIS COMPLETED FORM MUST ACCOMPANY ALL SAMPLES SUBMITTED FOR ANALYSIS IN ORDER FOR SAMPLE TO BE ACCEPTABLE FOR EVALUATION** Customer Name: ICI 2-0 0 Ng Customer Email: Site Address: / Sampler Signature id , ft III Phone No. Fax No. Special Instructions: Temp "C: Analysis Re .uired Sample Remarks / Receipt Number Ice'4i2S1 o cr) C 7.5 u) a) I— u t% a c.) < L V/ 4 —I 1.': T 6 9 11.- ‹ V Sample Disposal 0 Return to Customer El Disposal by Lab No. Sample Identification Date Time No. of Containers Sampling Method Container Type Composite .. . 2u Glass Plastic 1 2,02.60/qq. I 2 /4,, itvoa t x X X 10 0.A.ys 2 202.00 ILI i • 2- z/q/zo w oo I )( X X icax.rr /-571)41 3 2Dzot) NI. 3 i /N/20 IMO I )( X X 4 5 6 la Relin shed • (Signatur Dale a. ,, 1 IZoto Time 16.4)b lb Received by Sig re) Date b621> Time MOO 2a ReI'• uishe. .y (Signature) Of uj Date 214442t) Time !SSC) 2b Rec ived by: (Signature) Date Time 3a Relinquished by: (Signature) Time 3b Received by: (Signature) Date Time Sample condition condition upon arrival at laboratory Temp 'C 2, 3 Received on ice (Circle One) ?T N Sample intact and acceptable for evaluation? (Circle One)(/ N Initials of personnel checking in sample: . -7/ C.' t, Sample disposed of by: (signature) Date: 91, jo 171, ebeci 22003 I i\.) Additional sample remarks: 1.-\.31\) Tamper Evident Custody Seal Number # di_ -AM +11\-, aLlaZ"Lit-EL,,Alir 1112211:11 =IF — Laboratory TSR Number 2ozooiLlgi