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C ustody and Analytical Request Record <br /> M 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 5440 9450 DATE:5/20/14 SSTF: S27503 TH S27510 <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: l-719-275-1669 <br /> Notify ELI prior to <br /> Receipt Temp <br /> Report Required For: POTWAAIWTP❑ RUSH sample �4o <br /> Other submittal for C <br /> Special Report Formats—ELI must be notified VS * w a additional charges Cooler <br /> prior to sample submittal for the following: rm w g U and schedulin <br /> 00 1-> o Custody Seal <br /> NELAC ❑ A2LA❑ Level IV❑ V�, o $ o Comments: y� <br /> Other 's l}3 U $ o Y/ <br /> EDD/EDT❑ Format ` OR <br /> �a + a n = E SBA Schedule Code: Intact <br /> z ffi C m I SW CODE 11 Y/.P — <br /> SAMPLEx Table 1 Signature <br /> IDENTIFICATION Collection Collection N o it Frequency 1, Y/k' <br /> (Name, Location, Date Time N n Match LAB ID <br /> Interval,etc) MATRIX <br /> > > ir �M_ Y/-I — <br /> SW-AWD 5/20/14 10:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 2 SWA001 5/20/14 10:50 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ k <br /> 3 SWBDIS 5/20/14 11:15 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 4 SWPL 5120114 11:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ OLo <br /> 5 SWOS SQ0114 12:15 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 6 SWBOS 5/20/14 12:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ ;' <br /> 7 SWGS 5/20/14 14:15 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 8 SWBPL 5/20/14 14:50 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ �€ <br /> ❑ ❑ ❑ o ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 10 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ o El ❑ <br /> v Custody Relinquished by: Bob Tennant DatefTime:5/21/14 16:30 Shipped by. FedEx Received by: Date/Time: <br /> I' Record Relinquished by: Date/Time: Shipped by: Received by:w Date/Timel.-a l f <br /> ° MUST be LABORATORY USE ONLY <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal ® Sample Type #of fractions J <br />