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Laboratory TSR Number Carbon Acceptance Number (CAN) <br />/2- 12- <br />(assigned by laboratory personnel) <br />CalgonCarbon <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" <br />Customer Name: (.9,011 I 9- I )--- <br />Customer Email• <br />Site Address: IIP <br />Sampler Signature ,- ...8 Phone No. Fax No. <br />Analysis Required Special Instructions: Temp "C: <br />lc/ No e <br />c :".. 4/) <br />di <br />I— <br />it) <br />2 <br />k7— <br />1. <br />.1 <br />"a , <br />-•tZ <br />y <br />1 <br />IRO <br />180-73514-04 <br />i <br />Chain <br />10HW <br />of Custody <br />Sample Disposal El Return to Customer CI Disposal by Lab No of Containers Sampling <br />Method <br />Con ainer <br />Type <br />No. Sample Identification Date Time Composite 13 0 m 0 Plastic a <br />4t) <br />'\[)--,.,. -•c. <br />\-.I <br />t't Sample Remarks <br />1 _--) 0 I / 0- ),6)- . ( <br />( ... 2A. 7 <br />P/P - ( X X X / O 64-) <br />3 <br />4 <br />5 <br />6 <br />Relinq tied by: (S. m) Date Time <br />r2/5 <br />Received by (Si 4ture) „, ,.• Date Time <br />/z /s .,-- <br />Relinquish • . '(Signature Date <br />i V5. <br />(47 <br />Time <br />/ 1/00 <br />-.7 <--- ,-,., e2--__ ii, /5-A., . <br />Received by (Signature) <br />-'‘ - i k <br />Date <br />I A -15 -1') <br />Time <br />( 17 / C C <br />Relinquished by: (Signature) Date Time Received by- (Signature) Date Time <br />Sample condition upon arrival at laboratory Temp °C Received on ice (Circle One) Y 1 N Sample intact and acceptable for evaluation? (Circle One) Y/ N <br />Initials of personnel checking in sample: Sample disposed of by: (signature) Date: <br />Additional sample remarks: <br />zdc