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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.7705 0782 5890 DATE: 7/03/14 SSTF: S27602 <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 /> ANALYSIS REQUESTED Notify ELI prior to Rece}Fjt Te=1 <br /> Report Required For. POTWNWYrP El RUSH sample �/, c C <br /> Other 41 submittal for / <br /> Special Report Formats—ELI must be notified = ..o �° a additional charges ler ID s <br /> prior to sample submittal for the following: m" t and schedulin CustodySal <br /> NELAC❑ A2LA❑ Level IV❑ $y a W o g Comments: i, <br /> Other 3 a_ O C g e Y N <br /> EDD/EDT❑ Format a As 8 t E S&A Schedule Code: Intact <br /> r ie t t N W GW CODE: Y l N <br /> SAMPLE r 0 a €� Signature <br /> YIN <br /> IDENTIFICATION Collection Collection m V '* z Fr Match LAB ID <br /> (Name, Location, Date Time r° m Y/N <br /> Interval, etc) MATRIX ~ <br /> Mine Refill 7/03/14 8:45 water 6 ❑ ® ® ® R IS ❑ ❑ ❑ ❑ ® ❑ Table 4 �- <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ LU <br /> s ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I� <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ F- <br /> e ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ m <br /> e ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ J <br /> v <br /> t0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0101 ❑ ❑ ❑ o <br /> Custody Relinquished by: Bob Tennant Date/Tim7/03/14 16:30 Shi ed by: FedEx Received by: DateTme: <br /> A Record Relinquished by: Datefrime: Shipped by: Received by: Date/Time: <br /> MUST be LABORATORY USE ONLY <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal® Sample Type #of fractions <br />