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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 7700 0988 9293 DATE:5/15/14 SSTF: S27485 <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 /> to �e�e< : RU : Notify ELI prior to R P <br /> Report Required For: POTWNVVVrP❑ RUSH sample o C <br /> Other submittal for <br /> Special Report Formats—ELI must be notified = .. S ° a F additional charges Cooler ID(s) <br /> prior to sample submittal for the following: ��„ o t and schedulin <br /> NELAC ❑ A2LA❑ Level IV❑ s a�N p o Comments: Cust Y y N a! <br /> Other 2 a E 8 Intact <br /> EDD/EDT❑ Format a E SBA Schedule Code: <br /> z o o °w ~ SW CODE'1 YIN <br /> SAMPLE a € N Table 1 Signature <br /> IDENTIFICATION Collection Collection m z Frequency 1, Y/N <br /> N Match LAB ID <br /> (Name, Location, Date Time Y/N <br /> Interval, etc) MATRIX : 0 ~ <br /> SW LLHG 5/15114 7:30 Water 3 ❑ ® ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O 1 ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ CL'A c)SISF5 .. <br /> ❑ ❑ o ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 10 0 <br /> 10 1 1 ❑ 1 ❑ ❑ ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> Custody Relinquished by: Bob Tennant Date(rime:5/16114 16:30 Shipped by: Fed Ex Received by: Date/Time: <br /> Record Relinquished by: Date/Time: Shipped by. Received by ate/Time: <br /> MUST be <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal ® LABO TORY USE ONLY <br /> co Sample Type #of fractions <br />