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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 17 703 35-76 1 f_7 DATE:6/16/14 SSTF: S27577 TH S27581 <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 /> r•-.at-- s� rj�`}-3�s= Notify ELI prior to IReceiptT <br /> Report Required For: POTWNWVTP❑ RUSHm samplep <br /> Other e # submittal for I.c `�C <br /> Special Report Formats—ELI must be notified .. a 1= additional charges Gpplrr I <br /> prior to sample submittal for the following: m w C P and schedulingc <br /> NELAC❑ A2LA❑ Level IV❑ s n3 0 Q 'S Comments: Custody$eai <br /> Other c A 2 vlRJ� <br /> EDDlEDT❑ Format E E S&A Schedule Code: Intact <br /> z r ' °0 a SW CODE§1 Y/N <br /> SAMPLE i <br /> € = Table 1 Signature <br /> IDENTIFICATION Collection Collection z° � Frequency)1, Y/N <br /> (Name, Location, Date Time 9 s N Match LAB ID <br /> Interval, etc) MATRIX > > 12 '` Y/N <br /> 1 SW AWD 6/16/14 12:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ w� <br /> 2 SW OS 6/16114 12:45 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> 3 SW BOS 6/16/14 13:00 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ .t <br /> 4 SW GS 6/16114 13:20 Water 1 ® ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ ® ❑ t 4 O p <br /> 5 SW 13PL 6/16114 13:35 Water 1 ® 010 ❑ ❑ ❑ D ❑ ❑ ❑ 0101 <br /> E4� <br /> s ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ WO <br /> r. <br /> 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 11:11 w <br /> 8 ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ ❑ ❑ ❑ <br /> 9 ❑ ❑ ❑ 10 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 10 ❑ ❑ ❑ O D D ❑ ❑ ❑ ❑ ❑ O <br /> Custody Relinquished by: Bob Tennant Daterrime:6/17/14 16:30 Shipped by: FedEx Received by: DaterTime: <br /> Record Relinquished by: Daterrime: Shipped by: Received by Date/Time: _IcEl <br /> 21 MUST be <br /> A Signed Sample Disposal: Retum to Client❑ Lab Disposal® LABORATORY USE ONLY <br /> Sample Typq #of fractions <br />