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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 7705 0782 5890 DATE:7/03/14 SSTF: S27603 TH S27604 <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 Recce{ Te p <br /> Report Required For: POTWNWVfP❑ € RUSH sample o C <br /> Other w ¢ submittal for ��,�,Ipr ID <br /> Special Report Formats—ELI must be notified .. 8 g i= additional charges �I <br /> r to sample submittal for the following: r°m i w o and schedulingL <br /> P p g: ~>4 a ° 7 Comments: Custody I <br /> NELAC ❑ A2LA❑ Level IV❑ aW� 0 0 Y N <br /> Other 0 a-- ;, 2 E Intact <br /> EDD/EDT❑ Format E �& C o F SBA Schedule Code <br /> z u r �' SW CODE 11 Y <br /> SAMPLE ID <br /> M € Table 1 Signature <br /> IDENTIFICATION Collection Collection ��� W z Frequency 1, Y/N <br /> (Name, Location, Date Time ° , Match LAB ID <br /> Interval etc MATRIX a = 12 Y/N <br /> ' SW AWD 7/03114 11:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ® ❑ - <br /> 2 SW BPL 7/03/14 11:45 Water 1 ® ❑ ❑ ❑ ❑ ❑ El ❑ ❑ ® El3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1110 <br /> - <br /> 5 ❑ ❑ ❑ ❑ O ❑ ❑ ❑ ❑ ❑ ❑ ❑ �.. <br /> 6 ❑ ❑ a ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ QC <br /> 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ CIO <br /> 9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ El El El ❑ ❑ oaa <br /> ,o El ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ L/ 7 <br /> v Custody Relinquished by:Bob Tennant Date/Time:7/03/14 16:30 Shipped by: FedEx Received by: Date/Time: <br /> CD a) Record Relinquished by: Date/Time: Shipped by: Received bytrMj DatW7ime: <br /> o MUST be ` <br /> °' Signed Sample Disposal: Return to Client❑ Lab Disposal® LABO TORY USE ONLY <br /> Sample Type #of fractions <br />