Laserfiche WebLink
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. 5524 1169 2647 <br />DATE: 8/07/13 SSTF: 527022 <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 - 3049 -cell <br />Invoice Address: <br />Invoice Contact: JoAnne Ary <br />Purchase Order #: <br />ELI Quote V <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 POTWMWTP ❑ <br />AlU € <br />V SIS <br />REQUESTED <br />Notify ELI prior to <br />RUSH sample <br />Reoeipt T p <br />° C <br />Other <br />Special Report Formats — ELI must be notified <br />g <br />F <br />submittal for <br />a additional charges <br />Cooler ID (s) <br />�.y e� <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />y <br />W* <br />8 <br />t~ and scheduling <br />Comments: <br />Custody I <br />3 <br />Y/8) <br />Other4 <br />EDDIEDT El Format <br />r <br />a <br />v <br />8 <br />F <br />S&A Schedule Code: <br />SW CODE 13 <br />s Table 1 <br />Frequency 4, <br />to <br />N <br />Sign* re <br />N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />C 1lection <br />< <br />Mat LAB I <br />(Name, Location, <br />Data <br />Time <br />= <br />_ <br />N <br />Interval etc ) <br />MATRIX <br />' <br />❑ <br />1 ❑ 1 <br />❑ <br />❑ <br />10 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 <br />- <br />2 SW ARH <br />SM7113 <br />9:10 <br />Water 7 <br />O <br />1 ❑ 113 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />Table 1 <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />to <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />1 ❑ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />© <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01 <br />,I-- <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />010--_ <br />rYt <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />130 <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant DateTme:8/07 /13 16:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: Date/Time. <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Tjo # of fractions <br />