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d <br />CD <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: Schwariz - <br />Tracking No 3692013 61723526 <br />DATE:7/9 /13 SSTF: S27015 and S27016 <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: POTWN WTP [I <br />ANALYSIS <br />I$EDUES'' <br />ED <br />Notify ELI prior t0 <br />RUSH sample <br />Receimp <br />Other <br />submittal for <br />C <br />Cooler D(s} <br />Special Report Formats — ELI must be notified <br />prior to sample submittal for the following: <br />.. o �� <br />Im <br />G <br />a addifional charges <br />and schedulin <br />'r <br />c <br />19 <br />Custody '*--I <br />NELAC [I A2LA ❑ Level IV E] <br />15 <br />0 <br />U <br />g Comments: <br />Other ED EDT El Format Format <br />0 <br />< <br />F <br />SBA Schedule Code: <br />Intact <br />z <br />o <br />V <br />06 <br />_� <br />I <br />2 <br />F SW CODE 11 <br />x Table 1 <br />� Frequency] 1, <br />YIN <br />Signature <br />YIN <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />a <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />YIN <br />Interval etc <br />MATRIX <br />' <br />' SW-ARH <br />7 -9-13 <br />1155 <br />Water3 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑» <br />2 SW -LLHG <br />7 -9-13 <br />1210 <br />Water3 <br />❑ <br />0 <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 />❑ <br />❑ <br />Cry <br />5 <br />01010 <br />❑ <br />1 ❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑` <br />6 <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 <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 />-- <br />10 <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Daterrime:7 /9/13 16:30 <br />Shipped by: FedEx <br />Received by: Date(Tirne: <br />Record <br />Relinquished by: DaterTime: <br />Shipped by: <br />Received by: L.) Date/Time: — <br />- <br />MUST be <br />Signed <br />Sample Disposal: Return to Client El Lab Disposal <br />LAB ATORY USE ONLY <br />Sam le Type # of fractions <br />