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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 7701 3436 1945 DATE:5/29/14 SSTF- S27491 TH S27498 _ <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: POTWWNTP❑ RUSH sample $ O C <br /> Other m M F submittal for Cooler ID(s)o <br /> Special Report Formats—ELI must be notified ..0 8' '� f= additional charges <br /> prior to sample submittal for the following: I o gm W o ° t- and scheduling Custody al <br /> NELAC ❑ A2LA❑ Level IV❑ o aN $ o o Comments: Y yn <br /> �3� <br /> ODD/EDT❑ Format `�ai a F SBA Schedule Code: Intact <br /> i >n o ai SW CODE 11 Y 1A <br /> a = Table 1 Signature <br /> SAMPLE o ^b <br /> IDENTIFICATION Collection Collection �1 o I z Fruen�1, Y/,N <br /> Match LAB ID <br /> (Name, Location, Date Time a <br /> Interval. etc) MATRIX _ Y/Al— <br /> ' SW-AWD 5/28/14F12:15 <br /> :25 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 2 SWA001 5/28/14 :45 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 3 SWBDIS 5/28/14 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 4 SWPL 5/28114 12:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 5 SWOS 5/28114 12:50 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 6 SWBOS 528114 13:20 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 7 SWGS 529114 9:00 Water 1 ® O ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 8 SWBPL 5/29114 9:15 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ -- <br />'I ❑01 10 0 _ <br /> 2 Custody Relinquished by: Bob Tennant Date/Time:5/29/14 16:30 Shipped by. FedEx Received by: DatefTime: <br /> Record Relinquished by: Date/Time: Shipped by: Received by: Date/Time:5130 q <br /> MUST be _ LABORATORY USE ONLY <br /> Signed Sample Disposal Return to Client ElLab Disposal ® Sample Type #of fractions <br />