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T <br />v <br />CD <br />N <br />Lam- ) /2A /r)RIF_S <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: COtfer Corporation <br />Tracking No.8088120 15000821 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215 -1750 <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />Report Required For: POTWANWTp <br />Other <br />Special Report Formats - ELI must be notified <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />Other <br />EDD/EDT ❑ Format <br />C IDENTIFICATION <br />(Name, Location, <br />Interval, etc <br />Ml"0 Refill <br />2 Sump 4 <br />3 <br />4 <br />5 <br />a <br />9 <br />10 <br />Project Name. Schwartz <br />DATE: 12/23113 SSTF: S27306 527311 <br />Contact Name: Frank Adamic <br />Voice: 1 -719- 275 -7413 ext. 204 <br />Invoice Contact: JoAnne Ary <br />Tel: 1- 719- 275 -7413 ext. 209 <br />Fax: 1- 719- 275 -1669 <br />Li <br />-Relinquished b <br />Record <br />Relinquished by: <br />MUST be <br />Signed <br />I Sample Disposal: <br />L <br />IQ <br />er a V <br />VON <br />1100 <br />>14 <br />Q� <br />A <br />Z <br />9 ? <br />t✓ <br />N <br />Collection Collection QiSk u°1 <br />Date Time <br />12 -23-13 <br />12/26/13 <br />Custody <br />-Relinquished b <br />Record <br />Relinquished by: <br />MUST be <br />Signed <br />I Sample Disposal: <br />=- =, aQon on a ao <br />■�raaQa aaMal oo <br />oOaaoOo mom E <br />aaaaaaraaaa <br />■�r�aBo SOON M <br />mom Can <br />��aaL7L7aOaC�aC1 <br />��t7[�L7L7t»D • p <br />��aaaaaraaao4 <br />Shipped ' <br />Sampler Name if other than Contact: <br />1- 303 - 642 -3893 mine phone <br />Bob Tennant 1- 719 - 371 - 3009 -cell <br />Purchase Order T—T EL i ;• <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />P additional charges <br />et✓ hedulin <br />and sc Comments: <br />E WA Schedule Code: <br />h GW CODE: <br />Fre uenc <br />un <br />131B <br />ao <br />ME <br />BE <br />Qa <br />BIB <br />Aa <br />va <br />w1roll <br />Received by: <br />Receipt Tern <br />Cooler lD�(sj Q C <br />Cush <br />Y1 IQ <br />Intact <br />Y/N <br />Signature <br />Y/N <br />Match LAB ID <br />Y/N <br />RM <br />Date/Time: - s <br />Date/Time: <br />RY USE ONL <br /># of fractions <br />er a V <br />VON <br />Sampler Name if other than Contact: <br />1- 303 - 642 -3893 mine phone <br />Bob Tennant 1- 719 - 371 - 3009 -cell <br />Purchase Order T—T EL i ;• <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />P additional charges <br />et✓ hedulin <br />and sc Comments: <br />E WA Schedule Code: <br />h GW CODE: <br />Fre uenc <br />un <br />131B <br />ao <br />ME <br />BE <br />Qa <br />BIB <br />Aa <br />va <br />w1roll <br />Received by: <br />Receipt Tern <br />Cooler lD�(sj Q C <br />Cush <br />Y1 IQ <br />Intact <br />Y/N <br />Signature <br />Y/N <br />Match LAB ID <br />Y/N <br />RM <br />Date/Time: - s <br />Date/Time: <br />RY USE ONL <br /># of fractions <br />un <br />131B <br />ao <br />ME <br />BE <br />Qa <br />BIB <br />Aa <br />va <br />w1roll <br />Received by: <br />Receipt Tern <br />Cooler lD�(sj Q C <br />Cush <br />Y1 IQ <br />Intact <br />Y/N <br />Signature <br />Y/N <br />Match LAB ID <br />Y/N <br />RM <br />Date/Time: - s <br />Date/Time: <br />RY USE ONL <br /># of fractions <br />