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Laboratory TSR Number Carbon Acceptance Number (CAN) <br />zoick538 <br /> <br />(assigned by labocatory 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: k-c)(0 1-7 C .53C6 <br />Customer Email:- <br />Site Address <br />fe Phone No, Fax No. Sampler Signature _ <br />Special Instructions: Temp °C: Analysis Required <br />I / No <br />Co <br />C r. w at <br />a c rzi <br />ci. o 0 <br />i.. <br />., <br />(.... <br />-4,---- --L. <br />cu <br /> <br />I <br />I— <br /> <br />\1,1,11111i <br />160-66845-01 <br />1 <br />Chain <br />, <br />111\1 <br />of Custody <br />I <br />Sample Remarks _ <br />Sample Disposal E Return to Customer LI Disposal by Lab No. of Containers Sampling <br />Method <br />Container <br />Type <br />No. Sample Identification Date Time Composite .0 0 0 <br />i.9 Plastic -)0/-90_53 I ...,, , <br />X X 5- / <br />/ i <br />6 <br />Reli citi),rged by: (Siva! e) Date <br />5 <br />, <br />Time Receive2.e. ignature) 4, <br />lir if ",-,--- ........_...< <br />Dale <br />5/Z 4-(/ <br />(i7 <br />Time Relinquis. -.. b Signature Date <br />'//eri <br />81 <br />Time <br />(WO 1 2-V5W' , - <br />Received by ignature) <br />/ <br />Date <br />.,57v- <br />Time <br />(>f' <br />' eiinquished by: ignature{ Date Time ' eived by - (Signature) Date Time <br />Sam' e condition upon arrival at laboratory Temp "C 1 Received on ice (Circle One) Y Sample intact and acceptable for evaluation? (Circle 0 ) Y N <br />Initifils of personnel checking in sample: --711/ Sample disposed of by: (Signature) Date: <br />Ad itional sample remarks: <br />Ce(_ .Sekt/ <br />41117.7.M. InfliVilimm.11101ME