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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 '7 8 o 3 q-S DATE:6/02114 SSTF: S27527 TH S27533 <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 81216-1750 Fax: 1-719-275-1669 <br /> Notify ELI prior to Receipt Temp <br /> Report Required For: POTWJWVYrP❑ RUSH M submittal for C . ID(s) <br /> C <br /> Other <br /> Special Report Formats—ELI must be notified ..a * a F additional charges <br /> prior to sample submittal for the following: ' o o 0 t and schedulin Custody <br /> NELAC[IA2LA ElLevel IV[13 o U ; Comments: Y/ <br /> Other Intact <br /> EDD/EDT❑ Format `� r E S&A Schedule Code: <br /> i .a SW CODE I 1 Y <br /> SAMPLE = Table 1 Signature <br /> IDENTIFICATION Collection Collection Z- a to a Frequency)1, Math LAB ID <br /> (Name, Location, Date Time N Y IN-- <br /> Interval, etc) MATRIX I ' ~ <br /> SW-AWD 6102/14 12:30 Water 7 ❑ D ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ 0101 <br /> °•_ <br /> 2 SWA001 6/02/14 13:15 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ ' <br /> 3 SWBDIS 6/02/14 14:15 Water 1 ® ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 4 SWPL 6/02/14 14:30 Water 1 ® 17 ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ 1 ® ❑ U oc <br /> 5 SWOS 6/02/14 14:50 Water 1 ® ❑ ❑ 1 ❑ ❑ ❑ 1 ❑ O ❑ ❑ ® ❑ <br /> 6 SWBOS 6/02/14 15:15 Water 1 ® D ❑ ❑ ❑ ❑ ❑ ❑ ❑ D ® ❑ -: <br /> 7 SWGS 6/02114 15:30 Water 1 M ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> e ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 10 ❑ ❑ ❑ ❑ j ❑ ❑ I ❑ ❑ ❑ ❑ ❑ ❑ <br /> Custody Relinquished by: Bob Tennant Daterrime:6/02/14 16:30 Shipped by: Fed Ex Received by: Date/Time: <br /> Record Relinquished by: Daterrime: Shipped by: Received by:IQ Date/Time:L <br /> MUST be LABORATORY USE ONLY <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal® Sample Type #of fractions <br />