Laserfiche WebLink
Laboratory TSR Number Carbon Acceptance Number (CAN) <br />20(i. 1,212- <br />iesstened by labor-piety petrzinnel) <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 V ** <br />Customer Name ,.9,01-4 19..) 2-- Customer Email: <br />Site Address: , IP <br />Sampler Signature • •': .-if or Phone No. Fax No. <br />Special Instructions. Temp °C: Artalys e Required <br />I 40" No <br />C :;.". cif <br />I— <br />ca C..— <br />Container <br />-4. <br />.., <br />..... i <br />-6. 11,1i <br />I <br />180-73514-04 <br />111111 <br />1 <br />1 1 <br />Chain <br />1111 <br />of Custody <br />i <br />Sample Disposal 0 Return to Customer 0 Disposal by Lab <br />E o .5 <br />Sampling <br />Method Type <br />No. Sample Identicatio fin Date Time Ill c o o <br />ci Z o <br />sa <br />2 Glass ] k"6 a. <br />gu <br />ti. is ri <br />;i <br />-. <br />'''''-ii Sample Remarks <br />_1-1 0 I "- / ;0112- <br />.70,_ <br />is <br />x og, <br />/),,i 7 / d-I .9- . e2- 4 / I X <1, <br />Jri ro-t /ak - -r-np uo i.j.kr Tft <br />-2_6)r71-212.-- <br />6 <br />Reling bed by. IS nml <br />, <br />Date Time Received by (S attire).. Date Time <br />/745 <br />Relinquish t • (Signature <br />/ #. " "75-- — <br />Date <br />t Z. <br />Time <br />/00 <br /><--...• I Z/tcL7 <br />, i 7 <br />Received by. (Signature) ,..J(/' <br />V ?-4;7 -0 <br />Date <br />0 "/517? <br />Time <br />( `/ 0 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 I N Sample intact and acceptable for evaluation? (Circle One) Y 1 N <br />Initials of personnel checking in sample: Sample disposed of by: (Sgnature) Date: <br />60c