2013-11-26_HYDROLOGY - M1977300 (5)

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v CD CD N m 0 N 4 C ustody and Analytical Request Record PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page .1 of 1 Company Name: Cotter Corporation Project Name: Schwartz - Tracking No 3692013 62625478 DATE:9 /05/13 SSTF: , S27131 Report Mail Address: Sampler Name if other than Contact: Cotter Corporation - Canon City Mill Contact Name: Frank Adamic 1- 303-642 -3893 mine phone PO Box 1750; Canon City, CO 81215 -1750 Voice: 1 -719- 275 -7413 ext. 204 Bob Tennant 1- 719- 371- 3009 -cell Invoice Address: Invoice Contact: JoAnne Ary Purchase Order #: ELI Quote #: PO Box 1750 Tel: 1- 719 - 275 -7413 ext. 209 Canon City, CO 81215 -1750 Fax: 1- 719 - 275 -1669 Report Required For. POTW/WWTP El ANAI, Y:`WS P-.o•.sl:.s.• F r, Notify ELI prior to RUSH sample R l t temp Other F submittal for o C Special Report Formats — ELI must be notified �� o additional charges C ler l ) prior to sample submittal for the foNowing: NELAC ❑ A2LA ❑ Level IV ❑ 10. y a o o e t and scheduling Custody, Sepal Comments: Other s a E e Y'�:Y EDD /EDT ❑ Format E M I S&A Schedule Code: Intact Z c j2 SW CODE 11 YIN ai W x X Table 1 Frequency 1, Signature YIN SAMPLE IDENTIFICATION Collection Collection a Match LAB I D (Name, Location, Date Time g YIN Interval etc MATRIX _ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ >- 2 SW BPL 9/05/13 13:25 Water 7 ❑ ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 4 ❑ ❑ ❑ ❑ 1010 ❑ ❑ 011310 ❑ 5 01010 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 8 ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 9 101 ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ r 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Custody Relinquished by: Bob Tennant DatelTime:9 /05!1316:30 Shipped by: FedEx Received by: Date/Time: Record Relinquished by: Date/Time: Shipped by: Received by: j/ Daterrime:9 —&°- r. MUST be Signed Sample Disposal: Return to Client ❑ Lab Disposal ® LABORATORY USE ONLY Sample T # of fractions