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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. 7d X 10`7Z -5- r DATE: 6105114 SSTs=: S27539, S27540 <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 /> =aus_Ys�s ecur.z� r� Notify ELI prior to <br /> Receipt Temp <br /> Report Required For: POTWNVWTP RUSH sample <br /> Other submittal fort--a--°C <br /> Special Report Formats—ELI must be notified ..o$ a additional charges Co Q�D(s) <br /> prior to sample submittal for the following: m and scheduling <br /> NELAC ❑ A2LA❑ Level IV❑ 40, o o Comments: Custody gal <br /> Other 3 a o t �J <br /> a i m 'o <br /> EDD/EDT❑ Format E a&a o o _ SBA Schedule Code: Intact <br /> z z � t 2 N GW CODE: Y/,PJ� <br /> SAMPLE 343 N : ir € C/0 Signature <br /> IDENTIFICATION Collection Collect ion �'m' w (n 0 - N z Fre uen Match LAB ID <br /> (Name, Location, Date Time m y W m �' <br /> Interval,etc) MATRIX a Y Lw-, <br /> ' MW 2 6105/14 12:30 Water 6 19 ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ F2 ❑ <br /> 2 MW 3 A 6M5/14 11:30 Water 6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ � <br /> 4 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ �C <br /> 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ �s <br /> 9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> N Custody Relinquished by: B b Tennant Date/Tim6/05/14 16:30 Shi by: FedEx Received by: Date/Time: <br /> ARecord Relinquished by: Date/Time: Shipped by: Received by: Date/Time:41,�� ,,1 q <br /> MUST be LABORATORY USE ONLY <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal ® _ Sample Type_ #of fractions <br />