2014-10-23_HYDROLOGY - M1977300 (3)

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Chain of Custody and Analytical Request Record PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1 Company Name: Cotter corporation Project Name: Schwartz - Tracking No.7706 7322 8495 DATE: 7/23/14 SSTF: S27590,S27594 Report Mail Address: Sampler Name if other than Contact: Cotter Corporation-Canon City Mill Contact Name: Frank Adamic 1-303-642-3893 mine phone PO Box 1750;Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 204 Bob Tennant 1-719-371-3009-cell Invoice Address: Invoice Contact: JoAnne Ary Purchase Order#: ELI Quote#: PO Box 1750 Tel: 1-719-275-7413 ext. 209 Canon City, CO 81215-1750 Fax: 1-719-275-1669 ANALYSIS REQUESTED Notify ELI prior to Report Required For. POTWNVWTP❑ $ RUSH sample Receipt Temp C Other submittal for Special Report Formats—ELI must be notified 1 ..O S � a additional charges Cooler ID(s)prior to sample submittal for the following: 8m and schedulin Custodyal NELAC❑ A2LA❑ Level IV❑ g o i? Comments: Y Other 3 C c iO EDD/EDT❑ Format ` o �' o m S&A Schedule Code. Intact _ C t : ry a GW CODE: Y/N a „ E = Signature SAMPLE n $ o 0 C Y/N IDENTIFICATION Collection Collection 41°01Lacn b F UAW Match LAB ID (Name, Location, Date Time o o eY/N Interval, etc) MATRIX ~ '- ~ �2 ~ 'Mine Refill 7/23114 9:15 Water 5 1 ❑ ® 1 ® ® ® ® ❑ ❑ ❑ ❑ ® ❑ Table 4 �►- 2 Sump 9 7/23/14 13;30 Water 6 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ Table 2 Z 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ LU 5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ B ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O ❑ ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1� e ❑ ❑ I ❑ ❑ ❑ ❑ ❑ © 1 ❑ ❑ ❑ ❑ I� 9 ❑ 01010 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ -� 0 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ W Custody Relinquished : Bob Tennant Date/Tim7/23/14 16:30 Ship by: FedEx Received by: Date(Time: dQ Off) N Record Relinquished by: Date/Time: Shipped by: Received by DatelTime: - c{-.e. MUST be LABORATORY USE ONLY Signed Sample Disposal: Return to Client❑ Lab Disposal ® I.Sample Type #of fractions