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Chain of Custody and Analytical Request Record e side. Page 1 of 1 <br /> PLEASE PRINT;provide as much information as possible. Refercorresponding <br /> Company Name:Cotter Corporation Project Name: Schwartz- <br /> Tracking No.7703 5814 4733 DATE:6/19114 SS7F: S27586, $27587 <br /> Sampler Name if other than Contact: <br /> Report Mail Address. Contact Name: Frank Adamic 1-303-642-3893 mine phone <br /> Cotter Corporation-Canon City Milt Bob Tennant 1-719-371-3009-cell <br /> PO Box 1750;Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 204 purchase Order#: ELI Quote#: <br /> Invoice Address• Invoice Contact: JoAnne Ary <br /> PO Box 1750 Tel: 1-719-275-7413 ext. 209 <br /> Canon City,CO 81215-1750 Fax: 1-719-275-1669 t <br /> ,.pa>tr-YS0 .;,, ..; €n, Notify ELI prior to Receipt Temp <br /> RUSH sample �.a ,C <br /> Report Required For. POTWNVWTP❑ _ submittal for Cooler <br /> - <br /> Other additional charges <br /> Special Report Formats-ELI must be notified " o and schedulin Custody goal <br /> prior to sample submittal for the following: ->� `; g Comments: Y/V <br /> NELAC❑ A2LA Q Level IV❑ is o t Is Q Intact `�' <br /> Other a t S&A Schedule Code: Y I a- <br /> = a 2 W GW CODE: <br /> EDDlEDT[I Format Signature <br /> N Y/N— <br /> SAMPLE W g ci v Z Frequency: Match LAB 1D <br /> IDENTIFICATION Collection Collection Y/N— <br /> ( 1.2 <br /> Name, Location, Date Time F -2Interval, etc) MATRIX '' <br /> 'Sump 8 6/18/14 16:0o waters ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> Table 2 <br /> Table 2 " <br /> 4 Sump 9 6119114 11:30 Water 6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ <br /> lip? <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> S ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ D ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 8 ❑ ❑ ❑ D ❑ ID a ❑ ❑ ❑ ❑ ❑ <br /> T ❑ ❑ D ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> a <br /> ❑ ❑ ❑ ❑ ❑ ❑ o ❑ ❑ ❑ ❑ ❑ <br /> o Received by-. Datelrime: <br /> N Custody Relinquished b : Bob Tennant Daterrim6/19M416:30 Shi ed by: FedEx Received by: Date/Time:C.[;�p 4 _ <br /> Record Relinquished by: Date/Time: Shipped by: Lp,BORATORY USE ONLY <br /> MUST be Return to Client❑ Lab Disposal® Sample T #of fractions <br /> Signed Sample Disposal: <br />