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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 Project Name: Schwartz - <br /> Tracking No.7984 9868 0057 DATE: 4/09/14 SSTF: S27455, S27457 <br /> Report Mail Address- Sampler Name if other than Contact: <br /> Cotter Corporation-Canon City Mill Contact Name: Frank Adamic 1-303-642-3893 mine phone <br /> PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 204 Bob Tennant 1-719-371-3009-cell <br /> Invoice Address: Invoice Contact: JoAnne Ary Purchase Order#: ELI Quote#: <br /> PO Box 1750 Tel: 1-719-275-7413 ext. 209 <br /> Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> AN11L ; ; RE:)UF51F.D Notify ELI prior to Receipt Temp <br /> Report Required For: POTW/VAWP❑ `s RUSH sample s <br /> Other submittal for C <br /> Special Report Formats—ELI must be notified a p additional charges Coo er ID(s) <br /> prior to sample submittal for the following: 1 o Tm>I and schedulingg' <br /> NELAC ❑ A2LA❑ Level IV❑ ` �U)� �, `_ Comments: Custody Seal <br /> Other E 3 a o o W e Y/N <br /> y a.a �, t E Intact <br /> EDD/EDT❑ Format a o d F E SBA Schedule Code : <br /> 2 r ~ N GW CODE: YIN <br /> C11SAMPLE N Signature <br /> YIN <br /> IDENTIFICATION Collection Collection a'Cal g 0 N m Z � FreaMatch LAB ID <br /> (Name, Location, Date Time o o <br /> Interval, etc) MATRIX ~ Y/N <br /> ' Mime Refill 4/09114 8:30 Water 5 ❑ ® ® ® ® ® ❑ ❑ ❑ ❑ ® ❑ Table 4 >- <br /> 2 sump 5 4/09/14 12:00 Water 6 M ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® FEI Table 2 <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ocgo <br /> 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 10 <br /> s y v ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> s ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ '10 <br /> ❑ ❑ ❑ tr6:f <br /> 9 ❑ ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ❑ ❑ <br /> cn 1a ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0101 ❑7Received <br /> mpCustody Relinquished b : Bob Tennant Date�m4/09/14 16:30 _ Shi d b : FedEx b : Date/Time: <br /> Record Relinquished by: Date/Time: Shipped by: eived by: Date/Time: <br /> MUST be LABOR61TORY USE ONLY <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal ® Sample T De #of fractions <br />