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v <br />CD <br />CD <br />N. <br />O <br />A <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. 3692013 61723526 <br />DATE: 7/17/13 SSTF: S27046 &S27047 <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 />Report Required For POTWNVWTP 11 <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />RUSH sample <br />Re p <br />Other <br />Special Report Formats — ELI must be notified <br />a <br />le o <br />submittal for <br />I additional charges <br />C <br />Cooler I s) <br />prior to sample submittal for the following:} <br />C and scheduling <br />Custody Seal <br />NELAC ❑ A2LA ❑ Level IV [I <br />Other <br />�, <br />g Comments: <br />e <br />Y <br />EDD/EDT ❑ Format <br />< <br />Code: <br />Inia � / N <br />N <br />GW CSchedule <br />Si ure <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />W <br />F uen <br />O/ N <br />Match LAB ID <br />(Name, Location, <br />Date <br />Trrne <br />Y / N <br />Interval, etc ) <br />MATRIX <br />M <br />MW -13 <br />7 -17 -13 <br />11:25 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />O <br />❑ <br />❑ <br />® <br />0 <br />- <br />2 MW-15 <br />7 -17 -13 <br />"-es— <br />Water6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />3 <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />010,0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Uj <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />❑ <br />❑ <br />❑ <br />❑ <br />F- <br />' <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o: <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />F0 <br />❑ <br />m <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />,o <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Reiin /shed T n Dat&7ime:7 /17 /1316:30 <br />IS hi <br />Oped by: Fed <br />Ex <br />Received by: DateJT'ime: <br />1 <br />Record <br />Relinquished by: DateMme: <br />Shipped by: <br />I Received by V Date/Time: -). JB —13 <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />ample Type # of fractions <br />