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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 7004 2730 DATE: 5/22/14 SSTF: S27512, S27513 <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 Receip Tin C <br /> Report Required For: POTWMN El RUSH sample <br /> Other submittal for `�lI <br /> Special Report Formats-ELI must be notified ..o g additional charges Cooler ID(s) <br /> prior to sample submittal for the following: o>Zm"i t and scheduling <br /> NELAC ❑ A2LA❑ Level IV❑ -6$y o Comments: <br /> Custody Seal <br /> Other 3-a � t a Y/ N <br /> EDD/EDT❑ Format E ` ' ~ " S&A Schedule Code: Intact <br /> t7- 9 N Y/N <br /> SAMPLE Ell r € GW CODE: Signature <br /> IDENTIFICATION Collection Colleaon g 0 � N Fre ue Match LAB !D <br /> (Name, Location, Date I Time m cn °° N A <br /> Interval, etc) MATRIX ~ 4 � Y/N <br /> * <br /> ' N1W 1 5/22/14 12:45 Water 6 ® ❑ ❑ 1 O ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ Table 2 <br /> 2 Mine Refill 5/2V14 10:45 Water I ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ci ❑ Table 4 �"- <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 U <br /> 5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> e O ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ - <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ r <br /> 11 ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ..�...r <br /> �0 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> N <br /> Custody Relinquished by: Bob Tennant Date/Tim5/22/14 16:30 Shipped by: FedEx Received by: Datelrime: <br /> A Record Relinquished by: Date/rime: Shipped by: Received by: ime: <br /> MUST be LABO RY USE ONLY <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal ® Sample Type #of fractions <br />