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C 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 Project Name: Schwartz - <br /> Tracking No 7988 5713 7867 DATE:5/14114 SSTF: S27476 TH S27484 <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 /> Notify ELI prior to Receipt Temp <br /> Report Required For: POTWNWVTP❑ RUSHsame submittal for <br /> — <br /> Other o a Cooler ID(s) C <br /> Special Report Formats—ELI must be notified F additional charges <br /> prior to sample submittal for the following: 8$M W w Q 0 9 and scheduling <br /> NELAC ❑ A2LA❑ Level IV❑ ay 9 p o 2 = Comments: Custody Seal <br /> Other E 3: <br /> EDD/EDT❑ Format a of S&A Schedule Code: Intact <br /> SW CODE I i Y/.At <br /> SAMPLEco <br /> '2 o W r Table 1 Signature <br /> IDENTIFICATION Collection Collection aiCM $ w �, z Frequency 1, Y/N'— <br /> (Name, Location, Date Time ° a Match LAB ID <br /> Interval, etc MATRIX > > ~ Y/Air <br /> SW-AWD 5/13/14 12:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 2 SWA001 5/13/14 12:45 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ = ' <br /> 3 SWBDIS 5113/14 13:05 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 19 ❑ <br /> 4 SWPL 5/13/14 13:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 5 SWOS 5/13/14 13:50 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ 4W_ <br /> 6 SWBOS 5113/14 14:15 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ Cl ❑ ❑ ® ❑ . <br /> 7 SWGS 5/13114 14:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 8 SWBPL 5/13/14 14:50 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ .i <br /> s SWFBRG I 5/14/14 10:45 Water 3 ❑ ® ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 01010 ❑ <br /> A Custody Relinquished by: Bob Tennant DatelTime:5/14/14 16:30 Shipped by: FedEx Received by: Date/Time: <br /> Record Relinquished by: Daterrime: Shipped by: Received by: DateTme:5 <br /> MUST be LABORATORY USE ONLY <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal ® Sample Type #of fractions <br />