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C ustody and Analytical Request Record <br /> AN W 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 77 p2, y--V% 616 a DATE:6l10114 SSTF: S27516 TH S27623 <br /> Sampler Name if other than Contact: <br /> Report Mail Address: <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 /> :NA6_.SWS 01:' zW-STEG Notify ELI prior to Recri e °p <br /> Report Required For: POTWNVfP❑ _� RUSH sample C <br /> W <br /> Other submittal for <br /> o a % additional charges C Rdy <br /> 1 ) <br /> Special Report Formats—ELI must be noted .. 8 o r <br /> B Q°>1 16 # w 0 t✓ and scheduling CusSeal <br /> prior to sample submittal for the following: u W°o °o o Comments: Y N <br /> NELAC❑ A2LA❑ Level IV❑ <br /> U o <br /> cc <br /> ODDlEDT❑ Format therQ ' S&A Schedule Code: Intact <br /> a YIN <br /> Z o ,n F SW CODE 1 <br /> = Table 1 Signature <br /> SAMPLE B e °� z° : Frequency)1, Y 1 N <br /> IDENTIFICATION Collection Collection a"°' o N m Match LAB ID <br /> (Name, Location, Date Time a Y/ N <br /> Interval etc MATRIX ~ <br /> SW AWD 6110114 9:45 Water 1 ® ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ❑ ® ❑ >� <br /> 2 SW A001 6/10/14 10:00 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 3 SW BDIS 6110/14 10:15 Water 1 S ❑ [I [I ❑ ❑ [1 El ❑ El ® ❑ i <br /> 4 SW PL 6110/14 10:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ HE3 <br /> El ❑ ® ❑ <br /> 5 SW OS 6/10/14 10:45 Water 1 S ❑ El ❑ ❑ ❑ ❑ ❑ El ® ❑ t <br /> 6 SW BOS 6/10/14 11:00 Water 1 S El ❑ ❑ El ❑ ❑ El [1 S El <br /> 7 SW GS 6/10114 11:15 Water 1 S ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 8 SW BPL 6110114 11:30 Water 1 S ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ El <br /> ❑ ❑ ❑ o ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Y... <br /> Relinquishe�by:�Bob Tennant Date/Time:6110l14 16:30 Shipped by: FedEx Received by: DatelTime: <br /> Custody Record Relinquishe DatelTime: Shipped by: Received by' DatelTime:MUST be LABORATORY USE ONLY <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal® Sample Type #of fractions <br />