Laserfiche WebLink
Laboratory TSR Number <br />lassignott by laboratory personnob <br />CalgonCarbon <br />A Ktoaray 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 />80-81562-03 Ch s n of Ctrs otty <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 />Q ' .e....- Customer Name: • .--• „. <br />Customer Email: <br />Site Address: <br />Sampler Signature •74efir IV Phone No. Fax No. <br />Special Instructions: Temp "C: Analysis Required <br />Remarks / Receipt <br />Number <br />Sample <br />ICe' / No <br />C) c <br />74 U' to I- <br />w <br />0 c <br />a <br />U t.) <br />< <br />I ', <br />.) <br />q) <br />(.. C./ <br />t...., <br />d't 1, <br />Fr) <br />..) <br />to <br />hO <br />Sample Disposal Ill Return to Customer 11 Disposal by Lab <br />No. Sample Identification Date Time No of Containers Sampling <br />Method <br />Container <br />Type Composite SI <br />12 o <br />co 0 co <br />0 Plastic 1 i H e5'S--. i yy/ <br />_ _ pe 11}% /0 D4e- <br />1 I <br />3 <br />4 <br />5 <br />6 <br />la R4 <br />. <br /> <br />,; is • . S <br /> <br />/i <br /> nal <br />- <br />Date <br />/ , <br />Time 7 <br />(3. "P' <br />lb Received by: IS attire) <br />---------'- <br />Date Time 2a Relinquished by (Signature) <br /> I <br />Date Time <br />...., <br />. rec•iva.y (S Date Time a Relinquished b Signature) Da e Time <br />l-(2o <br />3b R eiv i .. . . <br />14 f/r/ <br />Date . <br />c(1,11(ic <br />Time <br />(/ • 2 G <br />Sample condition upon arrival at laboratory _Temp "C Received on ice (Circl One)0/ N Sampl . nt.! t and acceptable for evaluation? (Circle One)/ N <br />Initials of personnel checking in sample: Jill (.) _ Sample disposed of by: (Signature) Date: <br />Additional sample remarks: Tamper Evident Custody Seal Number # <br />3