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Additional sample remarks: Tamper Evident Custody Seal Number # 22003 <br />ow, MI 110.1-111r L-111511102Arlit 0111=1 <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: 2.0 ZOO iliq <br />Customer Email: <br />Site Address: <br />Sampler Signature Phone No. Fax No. <br />Special Instructions: Temp "C: Analysis Re uired <br />Number <br />Ice 40141 <br />Clt <br />C <br />co <br />4) Li c <br />2 <br />Type <br />„, <br />i <br />ticn —I <br />ft' ti- <br />Sample Disposal Li Return to Customer Li Disposal by Lab <br />No. Sample Identification Date Time No. of Containers Sampling <br />Method <br />Container Composite Plastic 2,024C 1 0 111 GI 1 2 ,14e, icy co X X X <br />20Zoo 14 i - 2- 241/24 kV 00 I )( X X <br />ZDZO0 PP/. 3 2/q21 io: ebb I X . X <br />6 <br />la Relin ished • (Signatur Die <br />.1. a 1 <br />-1/Zobs <br />lime <br />16.4b <br />lb Received by Sig re) Date Time <br />1900 <br />2a Rel uished y: (Signature) Date Time <br />2b Rec ived by: (Signature) 1 2b Date <br />21 ‘112,3 <br />Time <br />iCY6 <br />3a Relinquished by: (Signature) ate Time 3b Received by: (Signature) Date Time <br />Sample condition upon arrival at laboratory Temp 'C 2 , i Received on ice (Circle One)-eir N Sample intact and acceptable for evaluation? (Circle Onerl N <br />Initials of of personnel checking in sample: .-7-7 Sample disposed of by: (signature) I Date: 91.40 El. abed Laboratory TSR Number <br />20zoolLict