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CD <br />CD <br />N <br />O_ <br />N <br />Chain of Custody and Analytical Request Record <br />MOM <br />WIN= A ME 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. 808812015000319 <br />DATE: 9125/13 SSTF: S27178 &S27179 <br />Report Mail Address: <br />Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill <br />Contact Name: Frank Adamic <br />1- 30342 -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 />Notify ELI prior to <br />Re Tgmp <br />Report Required For: POTW/WVVrP ❑ <br />RUSH sample <br />!FQ C <br />�I <br />Other <br />Special Report Formats — ELI must be notified <br />2 .. <br />a <br />submittal for <br />F additional charges <br />—� <br />Cooler ID(s) <br />prior to sample submittal for the following: <br />I oilm <br />t and scheduling <br />Custod al <br />Y <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />° Comments: <br />Y <br />Other <br />EDD /EDT [] Format <br />a <br />12 <br />E S&A Schedule Code: <br />Intact <br />z <br />�mi <br />N <br />1 <br />2 <br />= GW CODE: <br />� <br />Y / N <br />Signature <br />YIN <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />W <br />n Fr ueric : <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />< <br />Y / N <br />Interval, etc ) <br />MATRIX <br />'' <br />o <br />MW -15 <br />9 -25-13 <br />1215 <br />Water 6 <br />® <br />1 ❑ 1 <br />❑ <br />❑ <br />1 ❑ <br />1 ❑ <br />❑ <br />1 ❑ <br />1 ❑ <br />❑ <br />® <br />❑a <br />2 MW -13 <br />9 -25-13 <br />1430 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />® <br />01 <br />X <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />LAI <br />° <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />� I <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 />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: BQb Tennant Date/Time:9 /25/13 16:30 <br />1 Shipped <br />by: FedEx <br />Received by: Datetrime: <br />_Z41 VS <br />Record <br />Relinquished by: DatelTime: <br />Shipped by: <br />Received by: a,, Date/Time:9 <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Typ2 # of fractions <br />t7 <br />