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Laboratory TSR Number Carbon Acceptance Number (CAN) <br />(assigned by laboratory personna) <br />IN( CalgonCarbon <br />A Kuraray Company <br />CHAIN OF CUSTODY RECORD <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 />*.ruI rfMDI PTfl PnRM MuST ACCOMPANY ALL SAMPLES SUBMITTED FOR ANALYSIS IN ORDER FOR SAMPLE TO BE ACCEPTABLE FOR EVALUATION** <br />Customer Name: DOVJ PtC5Y—c) SC21 ty..c_lt.., 1)--C—' <br />Customer Email: <br />Site Address: qi Di_ L av,-- t2. at 0 R., rae\ '?i-ic-s\:y.N(-0) °AN-Nos-- <br />Sampler Signature Phone No. Fax No. <br />Special Instructions: Temp °C: Analysis Required <br />Sample Remarks / Receipt <br />Number <br />c Acceptance Testing 0 <br />Sample Disposal Return to Customer CI Disposal by Lab <br />No. Sample Identification Date Time No. of Containers Sampling <br />Method <br />Container <br />Type Composite cu <br />0 <br />cu Plastic D5 V:DC tP•4 <br />2_416 5-37 >5 <br />6 <br />by: (Signature) la Relinquished Date Time <br />/ r <br />lb Received by: (Signature) Date Time 2a Relinquished by: (Signature) Date Time <br />D te <br />lat ib <br />Time 3a Relinquished by: (Signature) Date Time 3b Received by: (Signature) Date Time <br />2b cc e• (Signature) <br />i <br />H 411 • <br />Sample condition upon arrival at laboratory Temp °C Z. 17 Received on ice (Circle One)CDNI Sample intact and acceptable for evaluation? (Circle One <br />Sample disposed of by: (Signature) Date: <br />n.. Initials of personnel checking in sample: ivtivt-F <br />Tamper Evident Custody Seal Number # <br />Additional sample remarks: <br />-cro C (A Coc)er .,