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OZ Po 61, @bed <br />Laboratory TSR Number <br /> <br />CALGON CARBON CORPORATION <br />Carbon Acceptance Laboratory <br />Mailing Address. P 0 Box 717. Pittsburgh. PA 15230-0717 <br />Sample Shipping Address: 3000 GSK Drive Moon Township 15108 <br />Phone (412) 787-6700 Fax (412) 787-4795 <br /> <br />CalgonCarbon 0 2 0 I <br />Ti Kuraray Company • <br />(assigned by laboratory personnel) <br /> <br />180-113233 Chain of Custody <br /> <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: Z.010 //0F3 Customer Email: <br />Site Address: <br />Phone No. Fax No. Sampler Signature: <br />Special Instructions: Temp °C: Analysis Required / <br />Sample Remarks <br />Ice te4/No Acceptance Testing .I) 1 <br />& ,n <br />4) <br />9 <br />t <br />-r <br />n 1 <br />-4 <br />‘1 <br />Sample Disposal --_] Return to Customer E Disposal by Lab No of Containers Sampling <br />Method <br />Container <br />Type <br />No. Sample Identification Date Time Composite . 0 <br />n.R2 <br />0 <br />(I) <br />co <br />CD Plastic 1 2 0 Z,01/0b • 1 <br />ii / / <br />zo ct , OD I "C /X X 31_,D-,y <br />2 2oZol10 7 " 5 i zo cra) I X X <br />3 <br />4 <br />5 <br />6 <br />Rei nqu s4d by (Signature) <br />I <br />Date <br />Oi k--/ <br />'/20 <br />Time <br />9 =cx) <br />Receive . (Signature <br />1 , <br /> <br />_......"---- 4 <br />Date <br />07:a <br />Time <br />1/41. Y 5 <br />Re quisbed by (Sig luTe) <br />6P. (-- - - -, il <br />Date <br />/7 iti ' ' ' r .--- <br />Time <br />L ‘ <br />Receive by (Signature) Date Time <br />i . c <br />Relinquished •y Signature) Dale Time Received by gnature) Date Time <br />Sample condition upon arrival at laboratory Temp °C: ,"-- ' Received on ice (Circle One) Y / N <br />,_ <br />Sample intact and acceptable for evaluation? (Circle Otte( ,)/ N <br />--' Initials of personnel checking in sample: )',. Sample disposed of by: (Signature) pate: OZOZ/1-1-4 I- Additional sample remarks: <br />00156