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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.7700 0988 9293 DATE: 5/16114 SSTF: S27488 <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, CO81215-1750 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 /> 7-4 A--Y-zV s�rUta z Notify ELI prior to <br /> Report Required For. POTW/WWTP[:1 RUSH sample R i t Tp <br /> Other a submittal for C <br /> Special Report Formats—ELI must be notified = .. 1 a i= additional charges CQoter ID(s) <br /> prior to sample submittal for the following: o "m and scheduling �` <br /> NELAC ElA2LA❑ Level IV❑ o �', s W Comments: Custody al <br /> 3 Y/ <br /> EDD/EDT❑ Format ¢ a A o o m 3 E SBA Schedule Code : Intact <br /> _ t t g N GW CODE: Y/N <br /> SAMPLE N : € � Signature <br /> IDENTIFICATION Collection Collection `° o Y/N <br /> m m N < Z Fr uen Match LAB ID <br /> (Name, Location, Date Time F o 1 N <br /> YIN <br /> Interval, etc) MATRIX <br /> ' Mine Refill 5/16/14 9:30 Water 4 ❑ ® ❑ ® ® ® ❑ ❑ ❑ ❑ M ❑ Table 4 - <br /> z ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑ <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 414 <br /> 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ tAo o SA D '= <br /> ❑ ❑ ❑ ❑ ❑ ❑ a ❑ ❑ ❑ ❑ ❑ Sri= <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ a ❑ ❑ ❑ ❑ <br /> 9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ _Ft: <br /> ❑ ❑ ❑ ❑ o ❑ ❑ ❑ ❑ ❑ ❑ a <br /> N Custody Relinquished b Tennan DatelTim5/16/14 16:30 Shipped by: FedEx Received by: Date/Time: <br /> ° Record Relinquished by: Date/Time.- Shipped by: Received by Date/Time: <br /> W MUST be LABO TORY USE O Y <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal <br /> Sample Type #of fractions <br />