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t ustody 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 150010 .79 7$ 1.2S-4 69y <br />DATE:2104114 SSTF: S27321 <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 -7I9- 275 -1669 <br />EM i; S'7 <br />a k: <br />Notify ELI prior to <br />Re p <br />VW <br />Report Required For: POTW/YTP El <br />RUSHsample <br />o C <br />Other <br />Special Report Formats — ELI must be notified <br />� .. <br />.- <br />a <br />submittal for <br />F additional charges <br />ler ID(s) <br />prior o sample submittal for the following: <br />�'� <br />o <br />g <br />t and schedulin <br />Custody Seal <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />� <br />Comments: <br />Y /� <br />Other <br />EDD /EDT [] Format <br />`� <br />� <br />co <br />E <br />~ <br />S&A Schedule Code: <br />Intact <br />YIN <br />z � <br />_ <br />SW CODE '1 <br />x Table 1 <br />Signature <br />SAMPLE <br />z <br />Frequency 1, <br />Y / N <br />IDENTIFICATION <br />Collection <br />Collection+ <br />� <br />� <br />r <br />Match ID <br />(Name, Location, <br />Date <br />Time <br />Interval etc ) <br />MATRIX <br />SW -AWD <br />2/04114 <br />9:15 <br />Water 7 <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 <br />== <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />4 <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 />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑µ <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 />C {l?ZOl <br />9 <br />❑ <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: Bob Tennant Date/Time:2 104/14 16:30 <br />Shipped by: FedEx <br />Received by: Date/7ime: <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 />LABOF13TORY USE ONLY <br />Sample Type # of fractions <br />