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(assigned by laboratory personnel) Initials of personnel checking in sample: p/17°3 . . . 1Sample condition upon arrival at laboratory 'Temp °C Rei-e1Ced by: (Signature) Relinquished by: (Signature) cp co -p- co no — z <br />P ISample Disposal Lii Return to Customer ID Disposal by Lab ij if/ # VS)/ 1--eiJ :suoiloruisui lepeds Phone No. Site Address: 012 O S. t /4tAiri . Ce2yi ,Pre car . Customer Name: (I\ (r\ <br />t <br />>N <br />-...... Sample Identification Identification , v <br />c3c, 3 , a , <br />* <br />‘14 It'4 P <br />,- <br />o , 0 Fax No, t_i tx3 vi r..-1 <br />3 rAelinqurshed by: (Signature) Receive/ .y:40* . 1./...:// 4. \ <br />--, <br />A <br />, <br />4 <br />, No. of Containers Sample disposed of by: (Signature) Date: Received on ice (Circle One)C1')N 1Sample intact and acceptable for evaluation? (Circle One1`7) N <br />a <br />Composite Sampling Method Ice: Yes / No Temp °C: Grab <br />CD s., ......0 Glass 0 <br />0 <br />Plastic <br />=i B 0, <br />, i N, . <br />c c, , , Acceptance Testing Analysis Required Sampler Signature Customer Email: Received by: (Signature) Relinquished by: (Signature) Sample Remarks 0 <br />%..' <br />0 <br />%-' <br />7 <br />3 co <br />7 <br />3 co <br />zi> L17 Mailing Address: P.O. Box 717, Pittsburgh, PA 15230-0717 Carbon Acceptance Laboratory NOI1V210d2103 NOEINVO NOO1V9 JaqwnN itioleJoqe-1 Carbon Acceptance Number (CAN)