Laserfiche WebLink
ZffA7&-l—AZff4- Chain of Custody and Analytical Request Record <br />PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Pagel of 1 <br />Company Name: Cotter Corporation <br />Project Name: Schwartz - <br />Tracking No. 3692013 61723502 <br />DATE: 7/23/13 SSTF: S27081 <br />Report Mail Address: <br />Sampler Name if other than Contact <br />Cotter Corporation - Canon City Mill <br />Contact Name: Frank Adamic <br />1- 303.842 -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 #: <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 />Report Required For POTWNVWTP ❑ <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />RUSH sample <br />R <br />°C <br />Other <br />Special Report Formats -- ELI must be notified <br />.. <br />a <br />a rgeS <br />� additional charges <br />I s <br />prior to sample submittal for the following: <br />g <br />C and scheduling <br />Custody Seal <br />NELAC ❑ A2LA C] Level IV El <br />W> <br />.. <br />_ <br />Comments: <br />Other <br />EDD /EDT Format <br />3 <br />` <br />$ <br />' <br />o <br />? <br />t <br />E <br />S&A Sdtedule Code. <br />Intact <br />Z <br />N <br />t <br />t✓ <br />it <br />12 <br />~ <br />GW CG+DE: <br />Y / N <br />SignaturN <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Coliecxron <br />9 <br />� <br />� Fre uen <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Y / N <br />Interval, etc ) <br />MATRIX <br />Mine Refill <br />7123113 <br />9:10 <br />Water 5 <br />❑ <br />® <br />IM <br />1 ® <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />Biweekly <br />2 <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3 <br />© <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />r iam oqag <br />L,u <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />F0 <br />❑ <br />S <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />f D <br />❑ <br />oc <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />© <br />❑ <br />❑ <br />cc <br />$ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />-� <br />10 <br />❑ <br />❑ <br />" <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Rel shed by: Bob T n Dateffirne:7/23/1316:00 <br />Shipped <br />by: <br />FedEx <br />Received b . DateTme tlM <br />Record <br />Relinquished by-. Daterrime: <br />Shipped by: <br />Received by: Date/Time: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal 10 <br />LABORATORY USE ONLY <br />Sam le Type # of fractions <br />0, <br />ba <br />If <br />