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ANTENT 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. 8088120 15000586 <br />DATE: 11/13/13 SSTF: S27218 <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 #: <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 -1069 <br />;fz.s.._,M•.�.a <br />Notify ELI prior to <br />Rece' <br />pC <br />Report Required For: POTWNVWTP ❑ <br />RUSH sample <br />r C_ <br />Other <br />Special Report Formats — ELI must be notified <br />1 <br />submittal for <br />Q additional charges <br />Cooler ID(s) <br />for following: <br />90 <br />and scheduling <br />prior to sample submittal the <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />Other <br />r� <br />s ~ <br />Comments: <br />Custod I <br />y <br />Y <br />a <br />a Code: <br />Intact <br />D /EDT ❑Format <br />S&A Schedule <br />Z <br />m <br />GW CODE: <br />YIN <br />N <br />o <br />N <br />Signature <br />SAMPLE) <br />a�i�, <br />x <br />� <br />YIN <br />IDENTIFICATION <br />Collection <br />Collection <br />W <br />F uen r: <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />a3 <br />� <br />YIN <br />Interval, etc) <br />MATRIX <br />IOW-1 <br />11 -13 -13 <br />1320 <br />Water 6 <br />® <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />® <br />D <br />2 <br />❑ <br />o <br />❑ <br />D <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />3 <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />4 <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1:110 <br />❑:r <br />❑ <br />❑ <br />D <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />01 <br />94 <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />DID <br />❑ <br />=,f <br />7 <br />0,0 <br />0 <br />D <br />0 <br />a❑❑❑ <br />a <br />D <br />8 <br />010,0 <br />0 <br />1 0 <br />1 ❑ <br />❑ <br />O <br />❑ <br />D <br />❑ <br />❑ <br />9 <br />01010 <br />D <br />❑ <br />a <br />D <br />❑ <br />❑ <br />D <br />❑ <br />D_ <br />10 <br />0 <br />1 0 <br />❑ <br />❑ <br />❑❑ <br />D <br />0 <br />D❑ <br />D <br />Custody <br />Relinquished by: Bob Tennant Date/Time:11 <br />/13/1316:30 <br />Shipped <br />by: FedEx <br />Received by: Date/Time: <br />/4-'.340 <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: Date/Time: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONL <br />Sample Type # of fractions <br />