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and Analytical Request Record , of 1 <br /> Chain of Custody possible. Refer to corresponding notes on reverse side. Page <br /> PLEASE PRINT; provide as much information as <br /> Company Name: Cotter corporation Project Name: Schwartz - <br /> Tracking No.7704 0754 1943 DATE:612404 SSTF: S27545 Sampler Name if other han tact: <br /> 1-303-642-3893 mine phone <br /> Report Mail Address: Contact Name: Frank Adamic gob Tennant 1-719-371-3009-cell <br /> Cotter Corporation-Canon City Mill Voice: 1-719-275-7413 ext. 204 purchase Order#: ELI Quote#: <br /> PO Box 1750;Canon City, CO 81215-1750 Invoice Contact: .loAnne Ary <br /> Invoice Address: Tel: 1-719-275-7413 ext. 209 <br /> PO Box 1750 ELI prior to <br /> Canon City, CO 81215-1750 Fax: 1-719-275-1669 Notify Receipt Temp <br /> ANALY5kS r? esreo RUSH sample L"D C <br /> submittal for Cooler ID(s) <br /> Report Required For: POTWMYWTP❑ a additional charges Cam_ <br /> < <br /> Other to t and schedulin Custody Seal <br /> iko� e Comments: Y!1 1 <br /> Special Report Formats—ELi must be notified CO�>� � <br /> prior to sample submittal for the following: 3 0 7 ° Si�A�hedule Code: Intact <br /> NELAC[� A2t A❑ Level IV❑ E Y!Ids <br /> Other t g <br /> F GW CODE: Signature <br /> EDD/EDT❑Format = Y!N� <br /> = 1° Match LAB ID <br /> v L z a F <br /> SAMPLE U $ 16 Y!ICY <br /> IDENTIFICATION Collection Collection ai N A m <br /> {Name, Location, Date Time in -6 a °T ~ " <br /> MATRIX ❑ ❑ ® ❑ Table 2 <br /> interval,etc <br /> i ❑ ° ❑ ❑ <br /> � <br /> 'Mw-00 6/24l14 16:00 Water 8 ® ❑ ° El ❑ Cl ❑ ❑ Cl <br /> ❑ ❑ ❑ ❑ ❑ ° <br /> 2 ❑ ❑ ❑ ❑ ❑ ❑ ° ° ° ❑ ❑ ° <br /> 3 ❑ ❑ ❑ ❑ ° ° <br /> ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ , o ----- <br /> ° ❑ ° ° ° <br /> ❑ ❑ ❑ ❑ <br /> s ❑ ❑ ❑ ❑ ° ° ° ° Date[Time: <br /> ❑ ❑ ❑ ❑ Received b DatelTime:l <br /> 10 Shi d b : FedEx <br /> Received by'. <br /> Custody Re{i utshed b : Bob Tennan Date/Tim6/24/14 16:30 Shipped by: LABORATORY USE ONLY <br /> DatelTime: #of fractions <br /> Record Relinquished by: Sam le�rn �._=— <br /> MUST be Lab Disposal® �_ <br /> Signed <br /> Sample Disposal: Return to Client 0 <br />