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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 15000609 <br />DATE: 11/15113 SSTF: 527276 <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 #: 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 />A gar. <br />� ', -)S <br />Notify ELI prior to <br />R P <br />Report Required For: POTWNWVrP ❑ <br />RUSH sample <br />o C <br />Other <br />Special Report formats — ELI must be notified <br />e <br />g .. o �' <br />a <br />submittal for <br />a additional charges <br />Cooler ID(s) <br />, <br />prior to sample submittal for the followin <br />p p 9 <br />m'� <br />8'- > <br />and schedulin <br />9 Comments: <br />Custody Seal <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />€3 <br />W <br />Q <br />Y / N <br />Other <br />iii a <br />S8A Schedule Code: <br />IntactY <br />EDD /EDT ❑ Format <br />z <br />F GW CODE: <br />/ N <br />I <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Frecuenc : <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Y / N <br />Interval, etc ) <br />MATRIX <br />1 Sump -5 <br />11- 15..13 <br />1300 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />�° <br />2 <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />iU <br />• <br />❑ <br />© <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />010. <br />' <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />[:1 <br />0 <br />❑ <br />❑ <br />❑ <br />11 <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑., <br />7 <br />❑ <br />❑ <br />DI <br />❑ <br />10 <br />1:11 <br />D <br />❑ <br />01 <br />❑ <br />❑ <br />❑ <br />; <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />❑ <br />Custody Relinquished b :Bob Tennant Date/Time:11 /1511316:30 Shipped by: FedEx <br />Received by: Datelrime: <br />Received b Daterrime: <br />Record Relinquished by: Date/Time: Shipped by: <br />MUST be <br />Signed Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LAB TORY USE ONLY <br />Sample T # of fractions <br />