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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 8431 9524 DATE:4/08114 SSTF: S27456 <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 /> Carton City, CO 81215-1750 Fax: 1-719-275-1669 <br /> ANALvsrS rtEOUESTED Notify ELI prior to Receipt Temp <br /> Report Required For: POTW/WVIFrP❑ RUSH sample submittal for �--��C <br /> Other <br /> Special Report Formats—ELI must be notified = ..0 8 <br /> jg � additional charges r ID s prior to sample submittal for the following: F 7$ and scheduling Custod ,Wl <br /> NELAC El ❑ Level N❑ a t o e Comments: <br /> Y j04) <br /> Other Intact <br /> <A t ; '9 S&A Schedule Code: <br /> EDD/EDT❑Format z' t N GW CODE: Y/N <br /> 4 € = Signature <br /> n Z3 � : C YIN <br /> SAMPLE S w g u v Z W Frequency: Match LAB ID <br /> IDENTIFICATION Collection Collection0; <br /> (Name, Location, Date Time ` o c Y/N <br /> Interval, etc MATRIX ~ ~ ~ <br /> '(Nw-� 4/08/14 14:10 Water 8 <br /> ® rcr-31 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ Table 2 �^ <br /> 2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ❑ <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ UJI <br /> ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ❑ ❑ ❑ p <br /> 5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ a <br /> T ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 49 <br /> 49 <br /> ,o ❑ ❑ Li ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Relin wished b : B b Tennant DateRm4108/14 16:30 Shipped by-, FedEx Received b : DateTme: <br /> o 7Record <br /> Received b : te/Time: _ <br /> Relinquished by: DatefTime: Shipped by: Y LABO ORY USE ONSample Disposal: Return to Client❑ Lab Disposal® Sam le T #of fractions <br />