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Chain of Custody and Analytical Request nReco®arse side. Page 1 of 1 <br /> PLEASE PRINT; provide as much information as possible. Refer to corresponding <br /> FReport <br /> Name:Cotter corporation Project Name: Schwartz- <br /> No.798(3 .3 717 18� DATE:4/23114 SSTF: S27445 <br /> Sampler Name if other than Contact: <br /> ail Address: 1-303 642-3893 mine phone <br /> Contact Name: Frank Adamic Bob Tennant 1-719-371-3009-cell <br /> rporation-Canon City Mill Voice: 1-719-275-7413 ext. 204 <br /> PO Box 1750;Canon City, CO 81215-1750 Purchase Order#: ELI Quote#: <br /> invoice Address: Invoice Contact: JoAnne Ary <br /> PO Box 1750 Tel: 1-719-275-7413 ext. 209 <br /> Canon City, CO 81215-1750 Fax: 1-719-275-1669 Notify ELI prior to Receipt Temp <br /> RUSH sample 6.E5 °C <br /> Report Required For: POTWNVWTP submittal for Cooler ID(s) <br /> Other12 additional charges <br /> Report Formats—ELI must be notified 2m t a and schedulin <br /> Special Repo _ v t Custody Seal <br /> prior to sample submittal for the following: o b o ;z Comments: Y ktr <br /> NELAC ElA2LA❑ Level IV❑ " a,N _ 16 M 0 Intact <br /> E!a m E SgA Schedule Code: Y Mq <br /> Other a , c �' GW CODE: <br /> EDD/EDT ❑Format t '2 coN Signature <br /> Z C � Y 1A—" <br /> N LL e Z a Fr Match LAB ID <br /> �`°� <br /> SAMPLE Y 1 N -- <br /> IDENTIFICATION Collection Collection m N m W <br /> (Name, Location, Date Time x <br /> MATRIX r ~ <br /> interval,etc) Table 2 <br /> M1�V 8 4123/14 15:40 Water 6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> UJ <br /> 2 ❑ ❑ ❑ ❑ Cl ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 3 Cl ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 4 <br /> s ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Received b : Date/Time: <br /> ,o <br /> N Relin wished b : Bob Tennant DatelTim4/23/14 16:30 Ship, ed b : FedEx Received by: Date/Time:tllo7V 14A <br /> Custody Datefrime: Shipped by: <br /> Record Relinquished by: LP,BORATOR`(U5E ONLY <br /> MUST be #of fractions <br /> Signed Sample Disposal <br /> Retum to Client❑ Lab Disposal® Sample T e <br />