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v <br />CD <br />N <br />W <br />a <br />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 808812015000562 <br />DATE:11 /6/13 SSTF: S27254 <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 Omer #: <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 />ANALYSES <br />REQUESTE <br />-0 <br />Notify ELI prior to <br />Racal t e p <br />Report Required For POTWNWYTP ❑ <br />RUSH sample <br />*C <br />` <br />Other <br />Special Report Formats —ELI must be notified <br />o„ <br />9 <br />w <br />o <br />t <br />submittal for <br />F additional charges <br />a <br />Cool ID(s) <br />prior to sample submittal for the following: <br />Am <br />> <br />0 <br />V <br />1 <br />t and schedulin <br />Custody Seal <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />Other <br />3 <br />Comments: <br />e <br />�vj `, <br />EDD /EDT Format <br />❑ <br />`A <br />� <br />o <br />$ <br />.a <br />— <br />S&A Schedule Code: <br />�? SW CODE 11 <br />x Table 1 <br />Intact <br />Y <br />Signatl <br />SAMPLE <br />C <br />z <br />Frequency 1, <br />YIN <br />IDENTIFICATION <br />Collection <br />Collections <br />`° <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />> <br />a <br />� <br />YIN <br />Interval etc <br />MATRIX <br />> <br />SW BPL <br />1146 -13 <br />1340 <br />Water? <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />2 <br />010.0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />[3 <br />10 <br />❑ <br />3 <br />❑ <br />❑ I <br />❑ <br />❑ <br />❑ <br />I ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />=3 <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01 <br />> <br />6 <br />❑ <br />10 <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />10 <br />11113 <br />❑ <br />❑ <br />1 <br />CP <br />ll-.,. <br />7 <br />010,0 <br />❑ <br />10,0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />s <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />!01 <br />10 <br />❑ <br />❑ <br />11 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />74 <br />Custody <br />Relinquished by: Bob Tennan Date/Time:11f7 /13 16:30 <br />Shipped by: FedEx <br />Received by. Daterrime: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: LWO Date/Time: Al _ <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORWORY USE ONLY <br />Sample Type # of fractions <br />