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v <br />CD <br />N <br />A <br />AMU 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 55241169 2658 <br />DATE:8013 SSTF: S27019 <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 />REQUESTED <br />Notify ELI prior to <br />Receipt p <br />Report Required For: POTWMW E) TP <br />RUSH sample <br />o C <br />Other <br />Special Report Formats —ELI must be notified <br />.. <br />a <br />submittal for <br />a additional charges <br />Cooler ID(s) <br />prior to sample submittal for the following: <br />o <br />t and schedulin <br />Custod al <br />N�rC ❑ A2LA ❑ Level IV ❑ <br />s �, <br />2 Comments: <br />EDD /EDT ❑Format <br />a <br />o <br />� <br />� <br />� S&A Schedule Code <br />Intact <br />Y <br />SW CODE 11 <br />x Table 1 <br />Frequency 1, <br />a <br />Signature <br />Y /dt' <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />z <br />Match LAS 10 <br />(Name, Location, <br />Date <br />Time <br />Interval etc <br />MATRIX <br />' SW-AWD <br />8 -6-13 <br />1145 <br />Water? <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />�- <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 E <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 />5 <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />�... <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />m <br />9 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Date/Time:8/6 /13 16:30 <br />Shipped by: FedEx <br />Received by: Daterr ime: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: Date/Time:S J13 <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample T # of fractions <br />5 <br />