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v <br />CD <br />CD <br />N <br />0 <br />N <br />0) <br />C ustody and Analytical Request Record <br />MIMI 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 7,q 72 i z y . 3 Z$ <br />DATE:2/04 /14 SSTF: 527322 <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 -1669 <br />Report Required For. POTWNVWTP [I <br />Notify ELI prior to <br />RUSH sample <br />Receipt emp <br />' <br />Other <br />° <br />submittal for <br />C <br />Cooler ID(s) <br />Special Report Formats — ELI must be notified <br />.. S' <br />.- <br />a <br />i= additional charges <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />? �. >� <br />0 <br />w <br />$ <br />0 <br />0 <br />t and scheduling <br />'F Comments: <br />Custodyf al <br />Other <br />EDD /EDT C] Format <br />E a - <br />3 `% <br />U <br />2 <br />2 <br />Q <br />S&A Schedule Code. <br />Y C.% <br />Intac# <br />SW CODE 11 <br />Y/N <br />z° <br />x Table 1 <br />Frequency(i 1, <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />GOOF <br />N <br />Mat s ID <br />(Name, Location, <br />Date <br />Time <br />� <br />� <br />Y / N <br />Interval etc ) <br />MATRIX <br />° <br />° <br />SW -BPL <br />2104114 <br />10:15 <br />Water 7 <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />1 ❑ <br />❑ <br />1 ® <br />❑ <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />. <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑" <br />wmr)t ILA <br />r <br />5 <br />❑ <br />10 1 <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />01 <br />❑ <br />❑ <br />❑ <br />❑ 1 <br />❑ <br />ter, <br />6 <br />❑ <br />10 <br />❑ 1 <br />01 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 10 <br />❑ <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 />❑y <br />G <br />g <br />❑ <br />❑ <br />O <br />❑ <br />❑ 10 <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />p. <br />10 <br />❑ <br />❑ 10 <br />❑ <br />❑ 10 <br />1 ❑ <br />❑ 10 <br />❑ <br />❑ <br />O <br />Custody <br />Relinquished by: Bob Tennant DateMme:2/04 /14 16:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Record <br />MUST be <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: aterrime: -_� <br />Signed <br />Sample Disposal: Return to Client El Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Tyke # of fractions <br />