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Laboratory TSR Number Carbon Acceptance Number (CAN) <br />2ol 810 818 <br />0 <br />6 9 <br />Tamper Evident Custody Seal Number # -214Etel <br />5e..,/ ?V- _2/0 2o <br />CalgonCarbon <br />A Kuraray Company <br />CALGON CARBON CORPORATION <br />Carbon Acceptance Laboratory <br />Mailing Address: P.O. Box 717, Pittsburgh, PA 15230-0717 <br />Sample Shipping Address: 3000 GSK Drive, Moon Township, PA 15108 <br />Phone (412) 787-6700 • Fax: (412) 787-4795 <br />(assigned ey laboratory oersonnen OZ lo 61. e6ed 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: .2-0 is 08 18 Customer Email : <br />Site Address: <br /> <br />,/ ,,.. <br />Sampler Signature ,"7.. Phone No. Fax No. <br />Special Instructions: Temp °C: . *Analysis Required <br />I <br />CI) C 7.-... v) tu 1— <br />a) c.) c <br />IS a w <br />u <br />0 <br />"ip. <br />1111 <br />180-80873 <br />1 <br />03 <br />11111111111111111111 <br />Chain <br />Sample <br />of Custody <br />Remarks <br />Number <br />/ Receipt <br />1 <br />Sample Disposal El Return to Customer l -i Disposal by Lab No. of Containers Sampling <br />Method <br />Container <br />Type <br />No. Sample Identification Date Time 0 <br />zi 0 <br />El 0 f..0 11 u 15 Plastic 020i 90 93 1 8 • I /* 1 ! i <br />X A _A 5 big-j <br />20/gos3 / El. 2--(1 i d1 <br />6 <br />la Rely .uis•ed by 9 . urei Oat Time lb Received by: ignature) Data <br />ov 45 <br />Time <br />c-- <br />2a Relinquished by: (Signature) Date Time <br />2b Received by (Signature) Date Time 3a .Relin e y (Signature) <br />..------- <br />Date . Time <br />/3..Y. <br />3b Race, d by (Signature) , Date <br />i• ,. kk),.:,:bil -71 cf-i--/- <br />Time , <br />/ -7J I , % C /r t <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 I N <br />Initials of personnel checking in sample: Sample disposed of by: (signature) Date: <br />Additional sample remarks: