2013-11-26_HYDROLOGY - M1977300 (5)

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CD CD N U7 O_ N 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 808812015000197 DATE:9 /10/13 SSTF: S27157 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 Notify ELI prior to Receipt Temp Report Required For: POTWNVWTP ❑ RUSH sample o C Other submittal for -ID C r� Special Report Formats — ELI must be notified .. r 0 °o a F additional charges /I�D�S)�- =� prior to sample submittal for the following :m'! NELAC ❑ A2LA ❑ Level IV ❑ y'1 a and scheduling Comments: Custody Other EDD /EDT C] Format a' r `6 SBA Schedule Code: 3 Intact o o ~ z° SAN CODE 11 x Table 1 Frequency 1, Y / N Signature IDENTIFICATION Collection Collection �0°� R S Match LAB ID (Name, Location, Date Time ° W Y / N Interval etc ) MATRIX t SW -LLHG 9110113 13:35 Water 7 ❑ ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ 2 ❑ [1 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 Its 4 ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ �- 5 ❑ 1 1110 ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ �.., 6 ❑ 1 111 ❑ ❑ ❑ ❑ ❑ 10 ❑ ❑ ❑ ❑ � 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ c: 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ s it ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ to ❑ ❑ 10 ❑ 10 ❑ ❑ 10 ❑ ❑ ❑ Custody Relinquished by: Bob Tennant Daterrime:9 110/13 16:30 Shipped by: FedEx Received by: Date/Time: j 3 ;L Record Relinquished by: Date/Time: Shipped by: Received by: (,� Date/Time: Signed Sample Disposal: Return to Client ❑ Lab Disposal ® LABORATORY USE ONLY Sample Type # of fractions