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v <br />AMY Chain of Custody and Analytical Request Record <br />PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1 <br />Company Name: Cotter Corporation <br />Project Name: Schwartz - <br />Tracking No. 45931688 6372 <br />DATE: 7117113 SSTF: S27048 <br />Report Mail Address: <br />Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill <br />Contact Name: Frank Adamic <br />1- 303 -642 -3893 mine phone <br />PO Box 1750; Canon City, CO 81215 -1750 <br />Voice: 1- 719 - 275 -7413 ext. 204 <br />Bob Tennant 1- 719- 371- 3009 -cell <br />Invoice Address: <br />Invoice Contact: JoAnne Ary <br />Purchase Order it <br />ELI Quote #: <br />PO Box 1750 <br />Tel: 1- 719 -275 -7413 ext. 209 <br />Canon City, CO 81215 -1750 <br />Fax: 1 -719- 275 -1669 <br />VW <br />Report Required For: POTWNTP ❑ <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />RUSH sample <br />Rece Temp <br />Other <br />submittal for <br />C <br />Coo <br />Special Report Formats — ELI must be notified <br />to for the following: <br />.1-0>1 <br />a additional charges <br />f) <br />prior sample submittal <br />❑ A2LA ❑ Level lV ❑ <br />'s <br />t <br />t and scheduling <br />Comments: <br />Custody t <br />Other <br />E <br />� <br />Y /� <br />EDD /EDT ❑ Format <br />�' <br />t <br />S&A Schedule Code: <br />Inta <br />r <br />t <br />t <br />GW CODE: <br />x <br />`� <br />/ N <br />Sig uI <br />N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />W <br />#i <br />ti <br />ac F <br />Matc LAB ID <br />(Name, Location, <br />Date <br />Time <br />"�' <br />� <br />� <br />'' <br />d <br />N <br />Interval, etc ) <br />MATRIX <br />�' <br />i <br />' Main Refill <br />7/17/13 <br />11:15 <br />Water 5 <br />❑ <br />® <br />® <br />® <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />Biweekly <br />�- <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />Elio <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />W <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />cc <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01 <br />!-- <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />C9 <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />[ <br />g <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished Tennant Date/Time:7 /17/13 <br />16:00 <br />Shipped <br />by: <br />FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: DateiTime: <br />Shipped by: <br />Received by,�OV DateTme2: � <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />I ABOTWORY USE ONLY <br />Sample Type 0 of fractions <br />