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v <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No. 45931688 8420 DATE: 8/02113 SSTF: $27063 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Frank Ademic 1- 303-642 -3893 mine phone <br />PO Box 1750; Canon City, CO 81215 -1750 voice: 1- 719 - 275-7413 ext. 204 Bob Tennant 1- 719- 371 - 3009 -cell <br />Invoice Address: Invoice Contact: JoAnne Ary Purchase Order #: ELI Quote #: <br />PO Box 1750 Tel: 1- 719- 275 -7413 ext 209 <br />Canon City, CO 81215 -1750 Fax: 1 -719- 275 -1669 <br />fi•rfi g,. - �. -; * Notify ELI prior to Receipt Temp <br />Report Required For POTWNVWTP ❑ RUSH sample 1156 � 0 , C <br />Other submittal for z -- <br />- Special Report Formats — ELI must be notified a F additional charges poi (s} <br />prior to sample submittal for the folkywing: F�'� t and scheduling <br />NELAC ❑ A2LA ❑ Level N ❑ Custody l <br />� � � � Comments: Y 3t I Other EDD/EDT [] Format if< — SBA Schedule Code : Intact <br />Al A 1-- 40 <br />~ GW CODE: Y <br />SAMPLE 3 rj Signatu <br />* * Y <br />IDENTIFICATION Collection CdlecNon � Fro uenc : Matcfm LAB ID <br />(Name, Location, Date Time <br />Interval, etc ) MATRIX YIN <br />Mine Reg 8W13 9:45 Water 5 ® ® ® ® ❑ ❑ ❑ ❑ ❑ 1 ❑ ® ❑ Total Organic Carbon >- <br />2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />` ❑ 1 ❑ ❑ ❑ ❑ 1 ❑ 13,13 ❑ ❑ ❑ ❑ <br />' <br />01010 01010 ❑ ❑ ❑ ❑ ❑ ❑ <br />° ❑ ❑ ❑ ❑ O ❑ ❑ ❑ ❑ ❑ 0101 <br />' ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑_ <br />° ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ rµ <br />a jujolo ❑ jo ❑ ❑ ❑ I ❑ ❑ ❑ ❑ <br />10 ❑ 10 10 10 10 ❑ ❑ O ❑ ❑ ❑ ❑ <br />Custody RoMuished : ft ljnnNI Date/TimeSW/1314:30 Shi : FedEx Received by: DatdTime: <br />CD <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 />Record <br />Relinquished by: Datefrime: <br />Shipped by: <br />Received by: Date(Time :gjg <br />MUST be <br />Signed <br />Sample Return to Client ❑ Lab Disposal <br />LABORATORY USE ONLY <br />Sample T * of fractions <br />