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0 <br />N <br />0 <br />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 6475 <br />DATE: 7/10/13 SSTF: S27017 <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 #: <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 />ANALYSIS <br />REOUESTED <br />Notify ELI prior to <br />Receipt t Ty <br />Report Required For. POTW/WWTP ❑ <br />RUSH sample <br />- C <br />° <br />Other <br />Special Report Formats — ELI must be notified <br />submittal for <br />i= additional charges <br />_e <br />Cooler ID(s) <br />.. o <br />t <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />M <br />and scheduling <br />Comments: <br />Custody Sal <br />3 <br />' <br />Y /�I <br />EDD /EDT ❑ Format <br />< <br />E S&A Schedule Code : <br />Intact <br />H <br />€ <br />$ <br />F GW CODE: <br />Y / N <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Colledion <br />Collection <br />Fr uen <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />F <br />Y / N <br />Interval, etc ) <br />MATRIX <br />MW 19 <br />7110/13 <br />11:35 <br />Water S <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />Z <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />© <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />s <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />6 <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />0.010 <br />❑ <br />❑ <br />❑ <br />❑ <br />s~- <br />O <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />s <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />a� <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />io <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />1 ❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />O <br />Custody <br />Relinquished Tennant Date/Time:710 /13 16:00 <br />Shi <br />by: FedEx <br />Received by: Datelrime: <br />Record <br />Relinquished by: DateMme: <br />Shipped by: <br />Received by Date<rme: � ( (-{ <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABO TORY USE ONLY <br />Sample Type # of fractions <br />►s <br />