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CalgonCarbon <br />A kol.1,,,v <br />(assigned by laboraloty personnel) <br />80-8 562 03 Chain o Cue ody <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 />Additional sample remarks: Tamper Evident Custody Seal Number # <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. ..) (2 tt- _• ,' , 67) : s - ' 3 :2-- Customer Email <br />Site Address: <br />Sampler Signature <br />/ :_-....i <br />441 Waff <br />Required <br />I Receipt <br />Number <br />OLIN <br />Sample Remarks <br />Phone No. I Fax No. <br />Special Instructions: ' Temp "C Analysis <br />Ice/ No <br />ip <br />I— <br />c <br />oe <br />(-) c.) <br />ci. <br />c <br />151 <br />co <br />, <br />Ct.... <br />I <br />i,...,_—_. <br />-L <br />'3 <br />N-... .c) -..., <br />Nt, - <br />-- <br />Sample Disposal I. Return to Cuslomer Disposal by Lab Sample <br />No Sample Identification Date Time <br />ul <br />ai <br />1-= 5 o <br />"6 <br />o <br />Z <br />C a, Sampling <br />Method <br />Container <br />Type <br />`8 <br />g o 0 ,_ C <br />r- <br />C <br />- (7, v) 0 itl <br />a <br />(..) - ..e,; iio <br />--716 i 8 6' S a, L , /6 .,?/ <br />1 ,_z <br />4 <br />5 <br />l------ <br />6 <br />la Rr r- tsheAp S nate <br />lArailitatif . • eL wed' ry (SiTatCl <br />Date <br />• <br />Time „„. <br />,-.3 4 •)..„...---7" <br />lb Received by IS, natur()) Date Time 2n Relinquished by- (Signature) Date Time <br />Date Time a Relinquished b Signature) <br />/ <br />Date Time 3b R et . r • I - 7 <br />i <br />Date <br />-(1/q/( <br />Time <br />(/ ' 7 G <br />,-- <br />Sample condition upon arrival at laboratory Temp "C -I <br />--) <br />"-- Received on ice (Circki One 6.1 N Sampl: nt. 6 and acceptable for evaluation? (Circle One)a/ N <br />Initials of personnel checking in sample: )0 -V1 Li <br />1 <br />Sample disposed of by: (signature) Date: <br />-Eli ci, p z 1, a6ed Laboratory TSR Number <br />XVE, c.)1 52