Laserfiche WebLink
v <br />CD <br />m <br />0 <br />co <br />AW 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 808812015000210 <br />DATE:9 /19/13 SSTF: S27159 &S27160 <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 />Report Required For: POTW/WWPP 13 <br />ANAA.,MS <br />W - <br />0V USYED <br />Notify ELI prior to <br />RUSH sample <br />Receipt emp <br />Other <br />Special Report Formats — ELI must be notified <br />a <br />go <br />liki <br />submittal for <br />a additional charges <br />o C <br />Coder ID (s) <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />�m ,; <br />~ <br />t✓ and schedulin <br />Comments: <br />Custody Seal <br />s �', <br />v <br />Q <br />Y/ <br />EDD /EDT ❑Format <br />< <br />_ <br />S&A Schedule Code: <br />Intact <br />z <br />° <br />V <br />°_° <br />a <br />z <br />SW CODE 11 <br />x Table 1 <br />� Frequencyl 1, <br />YIN <br />Signature <br />YIN <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />s <br />W <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />V <br />C <br />$ <br />YIN <br />Interval etc <br />MATRIX <br />> <br />> <br />�' <br />' SW -AWD <br />9 -19-13 <br />1030 <br />Waterl <br />® <br />Elio <br />❑ <br />1010 <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />. <br />2 SW -BPL <br />9 -19-13 <br />1215 <br />Waterl <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Its <br />4 <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />y <br />5 <br />❑ <br />❑ 1 <br />❑ <br />O <br />1010 <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />1-._ <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />Eo <br />❑ <br />❑ <br />�a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennanj Daterrime:9/20 /1316:30 <br />Shipped by: FedEx <br />Received by: Date/Time: 9-`170 <br />Record <br />be <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by:C,,V Datemme: AZ <br />MUST <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />