2013-11-26_HYDROLOGY - M1977300 (4)

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d N O Chain of Custody and Analytical Request Record PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of Company Name: Cotter Corporation Project Name: Schwartz - Tracking No. 808812015000210 DATE: 9119/13 SSTF: S27162 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/WIIVTP C3 ANALYS£S RcoueS TFO Notify ELI prior to RUSH sample Receipt p Other Special Report Formats — ELI must be notified a submittal for additional charges 0 I.& C Gooier ID(s to sample submittal for the following: F t prior NELAC E] >'� and scheduling '2 Custody'S�Feal A2LA ❑ Level IV El y 3 Comments: Ocher R 4:v EDD/EDT [] Format i a 3 S&A Schedule Code Intact N € GW CODE: YIN Signature SAMPLE IDENTIFICATION Collection Collection z x Fre uen Match LAB ID (Name, Location, Date Time F YIN Interval, etc) MATRIX " MW -19 9 -19-13 1700 Water 6 ® ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ 1 ® ❑ - Z ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 3 ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ UJ ❑ ❑ ❑ ❑ ❑ ❑ o ❑ ❑ ❑ ❑ ❑ =31 5 010 ❑ ❑ ❑ ❑ 01010 ❑ 1 ❑ ❑ pl- s ❑ ❑ ❑ ❑ ❑ ❑ 01010 ❑ ❑ ❑ �... ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ e 11 ❑ El ❑ ❑ ❑ ❑ ❑ ❑ ❑ CIO s ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ � 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 01 Custody Relinquished by: Bob Tinngnt Detw Time:9/20 /13 16:30 Shi b : FedEx Received by: Date/Time: Record Relinquished by: Date/Time: Shipped by: Received by: Dater rime: -.aj-- MUST be Signed Sample Disposal: Return to Client ❑ Lab Disposal ® LABORATORY USE ONLY Sample Type # of fractions