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Laboratory TSR Number Carbon Acceptance Number (CAN) <br />itional samp e remar s: <br />Ca_ Se,,/ pacOo <br />74-( c,/ ou c-- <br />L( <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: co 1 c .53,i3 Customer Email:7- / <br />Site Address: - 9 <br />Phone No. I Fax No. Sampler Signature 44; a 1 Ai <br />Special Instructions: Temp °C: Analys s Required <br />I / NO <br />c <br />.7.2 <br />LI c <br />IS ce. <br />to t..) 0 <br />Type <br />,- <br />1. <br />:Y <br />(---J <br />• <br />\.) <br />c o I <br />Container <br />11 iS0-86645-01 <br />111 <br />Chain of Custody <br />II <br />\\\\ <br />Sample Remarks <br />Sample Disposal E Return to Customer Ili Disposal by Lab No. of Containers Sampling <br />Method <br />No. Sample Identification Date Time Composite .o <br />E <br />w In co ,- Plastic 1 :o/-70.53, I 1 / X X <br />C-) / 7 C.) • 5 3 8 .,._ <br />,t <br />2 1 / / <br />3 <br />4 <br />5 <br />6 <br />RelinquiAd by: (Sig* e/ <br />/ <br />/ <br />Date <br />, , / 7 <br />Time Receive2dk - gnature)11.. <br />mrp-Zor <br />, ----.-‹ Ail <br />1:)._ <br />5 ( Z117 <br />Time <br />12, y5 <br />Relinquis. - • Date <br />Sher/ <br />(17 <br />Time <br />( WO <br />Received by ignature) <br />/ <br />Date <br />7L111- <br />Time - elinquished by: ignature) Date Time eived by (Signature) Date Time <br />Sample condition upon arrival at laboratory Temp "C I • _1-1 Received on ice (Circle One) Y {ample intact and acceptable for evaluation? (Circle OiCi) N <br />lniti Is of personnel checking in sample: ..."--7A/ Sample disposed of by: (Signature) Date: <br />_ _ moms, ex, ea.-14.as ss. --ar <br />(assigned by laboratory personnel) <br />CalgonCarbon r:2oic-1.538