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Laboratory TSR Number Carbon Acceptance Number (CAN) <br />/212- <br />(assigned by laboratory personnel) <br />CalgonCarbon OZ 40 61. 96ed LI.OZ4Z/ZI, Sample Identification Date Time <br />Phone No. Fax No. <br />Special Instructions: <br />Time Relinquish,(Signature <br />Time Received by. (Signature) <br />Date Time <br />r-2/5 <br />Time Date <br />Sample disposed of by: (Signature) Date: <br />Additional sample remarks: <br />Ceit7*- <br />Initials of personnel checking in sample: <br />Customer Email: <br />Sampler signature <br />Analysis Required <br />I \JINNI! <br />Sample Remarks <br />Aig <br />Sampling <br />Method No of Containers Acceptance Testing Container <br />Type <br />Sample Disposal 0 Return to Customer El Disposal by Lab <br />3 <br />4 <br />5 <br />6 <br />Received by (yOriSture) -7 . <br />Relinquished by: (Signature) <br />Date <br />7, <br />/ <br />Date <br />/Z/S <br />Date <br />Z/ (5/ <br />Date <br />Time <br />,20 <br />Time <br />Sample condition upon arrival at laboratory Received on ice (Circle One) Y I N Sample intact and acceptable for evaluation? (Circle One) Y I N <br />c <br />Temp °C <br />Customer Name: „?....013 <br />Site Address: <br />No. <br />2 <br />Temp °C: <br />No <br />Relinq hod by: (S. re) <br />Received by (Signature) <br />2c) i <br />CALGON CARBON CORPORATION <br />Carbon Acceptance Laboratory <br />Mailing Address: P.O. Box 717, Pittsburgh. PA 15230-0717 <br />Sample Shipping Address: 500 Calgon Carbon Drive, Pittsburgh, PA 15205 <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**