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C 40 Z abed 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 1412) 787-6700. Fax. 1412) 787-4795 <br />CalgonCarbon <br />KI <br />Laboratory TSR Number <br />xv;o ; 5 :2_ <br />(05.,Intoti Ine 1.hrliatnry ovrieorwil <br />180 B1562-03 Chain of Gus ody <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 />.,,, .,"- -- , <br />Customer Name: .;2 Lk- V.,: ()/-- <br />Customer Email: <br />Site Address. <br />Sampler Signature Phone No. I Fax No. <br />Special Instructions' Temp "C: Analysis Required <br />Sample Remarks / Receipt <br />Number ---I <br />Iced;21/ No Acceptance Testing Container (2--e:•-: --. <br />c..„.:1' <br />-I. <br />3 <br />,.t.. <br />Zr-- <br />-• 4 <br />.) <br />Sample Disposal CL1 Return to Cusiomer ! Disposal by Lab No. of Containers Sampling <br />Method Type <br />No. Sample Identification Dale Composite Time r <br />0 Glass Plastic .---4(7 / 8 d'i S 2,. I 7/v/ i'41 rt, X /f .,)/-, <br />2 )0 40€16) ,)-- <br />i <br />/ 1 1 X <br />cip an ,,,...,A.4,.., I <br />te-PPO <br />u,f <br />5 03 i /0 010--, TA-- r ( i-D 73.-tb41,E3 <br />.. ...-' <br />la R isll . nos • <br />— <br />Date Time . b Received by (SI lalurel Date limp 2a Relinnuished by ISgnaiurei Dote Time <br />bi- lived* (Sitab Pi Date Tame .. a Relinquished b Sigriniulei <br />i <br />Da‘e Time <br />-) P2E , <br />3b R eiv yf <br />1 l <br />ante , <br />nil/46P <br />Time <br />N CI:t ? <br />Sample condition upon arrival at laboratory <br />4 . - Temp "C •-/ -- Received on ice (Circta OneCi N San plent t and acceptable for evaluation? /Cede One)/ N <br />Initials of personnel checking in sample: Jill. U Sample disposed of by: rsignalureo Date; <br />Additional sample remarks: Tamper Evident Custody Seal Number # ST7= <br />