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v <br />A <br />co <br />C ustody 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 o g g l �, o / S O OOZY/ <br />DATE:9/23/13 SSTF: S27098 $ S27099 <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 P <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 />ANALYSIS <br />REOUESTED <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For. POTWNWV rP El <br />RUSH sample <br />�� C <br />Other <br />Special Report Formats —ELI must be notified <br />o �° <br />�a <br />� <br />w <br />� <br />Q <br />G <br />submittal for <br />a additional charges <br />Gooier ID(s) <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />$ P> <br />o <br />8 <br />t+ and scheduiin <br />2 Comments: <br />Custody al <br />Other <br />y <br />°° <br />' <br />Y / <br />EDD/EDT ❑ Format <br />'� <br />�' <br />E S&A Schedule Code : <br />Intact <br />�= SW CODE 11 <br />Y / N <br />a <br />-- <br />r <br />x Table 1 <br />F uen 1, <br />Signature <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Y 1 N <br />Interval etc <br />MATRIX <br />> <br />> <br />~ <br />SW -AWD <br />9123113 <br />14 :00 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />y.- <br />2 SW-BPL <br />9123113 <br />13:50 <br />Water 8 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />rio <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />IU <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <br />❑ <br />1 ❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />y.e <br />6 <br />❑ <br />1 ❑ 10 <br />❑ <br />10 <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1�— <br />7 <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />,o <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Date/Time:9/2311316:30 <br />Shipped by: FedEx <br />Received by: Datelrme: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: " Datemme: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample T # of fractions <br />