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Laboratory TSR Number Carbon Acceptance Number (CAN) <br />20180818 CalgonCarbon <br />A Kutaray Company <br />CALGON CARBON CORPORATION <br />Carbon Acceptance Laboratory <br />Mailing Address: PO, 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 />lacsIgned oy loong';11nry r,emonnei) <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: .a.0 1308)8 _ Customer Email <br />. <br />Site Address: ,,, <br />...-"" <br />Sampler Signature Phone No. Fax No. <br />Special Instructions Temp "C - . tAnalysis Required <br />lofeCce9 No <br />s•-•—_- Crt c <br />*Z.1 to ai <br />a) r..) <br />C 15 <br />O. w <br />u u < <br />0 <br />-11. <br />180 80873-03 <br />Sample <br />Chain <br />1111111111111110 <br />of Custody <br />Remarks <br />Number <br />/ Receipt <br />Sample Disposal 1 Return to Customer i DIsposal by Lab <br />12 <br />(/) c <br />Sampling <br />Method <br />Container <br />Type <br />Sample Identification Date Time <br />to <br />E o <br />C.) <br />ii. <br />6 z <br />o <br />ca.o <br />E o u <br />I" 2 <br />0 <br />in <br />0 <br />0 <br />tri ro <br />1 ,20/ go 92 ( 8 s 1 34i, . !/ A A <br />2 I 20) &ay / e. 2- J I <br />5 bPi-j <br />____AL <br />5 <br />6 . <br />to Rey .uls•ed by ure) <br />Af "Ale, <br />Dale Time lb Received by gnaturei <br />( <br />Date Time 2a Reh -lmust-led by (Signature) Date Time <br />2b Received by (Signature) Dale Time 3a Reli 1 eri .y (Signature) <br />,- <br />Date ' Time <br />/3:t/i/. <br />3b Race, d by (Signature) , Dale <br />,-, <br />\A):;V.°111 7: -I -/z7,- <br />Time —J.. <br /> <br />I r. <br />/3 'frs , ,„. / §' <br />Sample condition upon arrival at laboratory Temp "C Received on ice (Circle One) Y / N Sample intact and acceptable for evaluation? (Circle One) Y / N <br />Initials of personnel checkin9 in sample: Sample disposed of by: (Signature) Date: <br />Additional sample remarks: <br />Tamper Evident Custody Seal Number # _ISERt7 <br />0X-- 5e/ 1:/- 42/0 2o