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II <br />(assigned by laboratory personnel) 180-113233 Chain of Ci stody 00Z/1- 00156 <br />Additional sample remarks: <br />CALGON CARBON CORPORATION <br />Carbon Acceptance Laboratory <br />Mailing Address - PC 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 />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.CLO 806 Customer Email: <br />Site Address: <br />_,-,-- <br />/ <br />Phone No. Fax No. Sampler Signature: , f /7 / <br />Special Instructions: Temp °C: Analysis Required <br />Sample Remarks <br />Ice: 1/ No rAcceptance Testing I. k <br />.) <br />E .9 ..r <br />4 A' =- -r <br />.1) <br />70; E z r•,.,-.• <br />g <br />Sample Disposal H Return to Customer L7 Disposal by Lab No of Containers Sampling <br />Method <br />Container <br />Type <br />No Sample Identification Date Composite Time ".; <br />_. <br />6 <br />w . <br />a 1Plastic 1 20Z,01 /0b • I <br />li b) //5 zo ctIOD 1 Y )( X 3D, <br />2 202„C.31 1 0 7 /5-ki, cra) I <br />3 <br />4 <br />5 <br />6 <br />Relinquis d by (Signature) <br />di i <br />(. <br />Date <br />t <br />/5120 <br />Time <br />T-cx) <br />Receive y (Signaturo• <br />./P <br />Date <br />/---,/ <br />Time <br />, •- — /e),•=7) <br />Re gLated by (Signature) _ <br />_. L_----, ../. / <br />Date <br />/ fl <br />Time <br />Receive by (Signature) Date fine Relinquished y Signature) Da e Time Received by Ignaturei Date/ Time <br />Sample condition upon arrival at laboratory Temp °C ,- Received on ice (Circle One) Y / N Sample intact and acceptable for evaluation? (Circle One()/ N <br />Initials of personnel checking in sample: -' i Sample disposed of by (Signature) Date: jo abed CalgonCarbon <br />11 Kuraray company II <br />Laboratory TSR Number