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. 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: Schwwft - <br />Tracking No. 55241169 2636 <br />DATE: 8107113 SSTF: x27021 & & 527023 <br />Report Mail Address: <br />Sampler Name if other than Contact <br />Cotter Corporation - Canon City Mill <br />Contact Name: Frank Ademic <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 -109 <br />Report Required For. POTWAMNTP ❑ <br />�f���.x.,�: <br />;.,- _.��x..•� <br />�: #; <br />Notify ELI prior to <br />RUSH sample <br />R7"?C <br />Other- <br />Special Report Formats - ELI must be notified <br />to sample submittal for the following: <br />°" <br />'' <br />F subm for <br />charges <br />t <br />Cooler ID(s) <br />prior <br />NELAC ❑ A2LA ❑ Level N [3 <br />n', <br />and scheduling <br />Comments: <br />Custody al <br />Other <br />e <br />; <br />EDD/EDT ❑ Format <br />~ <br />S&A Sdwdule Code: <br />intact <br />z <br />•a <br />�. SW CODE i 3 <br />N <br />Table 1 <br />Frequenayt 4, <br />Sig re <br />Y <br />SAMPLE <br />IDENTIFICATION <br />colon <br />lodi <br />Collection <br />Mat )NAB ID <br />(Name, Location, <br />Dab <br />Time <br />/ N <br />Interval etc ) <br />MATRIX <br />> <br />1 SW FBRG <br />V07113 <br />8:15 <br />Water 3 <br />❑ <br />® <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />D <br />® <br />❑ <br />Code 3 <br />._ <br />z <br />❑ <br />o <br />01010 <br />❑ <br />o <br />❑ <br />o <br />❑ <br />® <br />o <br />. <br />3 SW LLHG <br />8107/13 <br />m2o <br />Water 3 <br />D <br />to <br />® <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />® <br />❑ <br />Code 3 <br />t _. <br />' <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />s <br />❑ <br />o <br />o <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o 113 <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />o <br />o <br />❑ <br />❑ <br />❑ <br />' <br />D 10 <br />❑ <br />0_1 <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />.t <br />a <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />D <br />D <br />❑ <br />❑ <br />❑;' <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: DQUIDnimt Date1T'ime:8/07 /1316:30 <br />Shipped by. FedEx <br />Received by: Date/ Time: <br />41 e <br />Record <br />MUST be <br />Relnquished by: Date/Time: <br />Shipped by: <br />Received by: me: DaWTi - } <br />Signed <br />Sample Disposal: Retum to Client Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample T #01f fiacfions <br />R <br />