Laserfiche WebLink
C ustody and Analytical Request Record <br /> A!UPLEASE 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 7706 7322 8495 DATE:7/23/14 SSTF: S27591 TH S27592 <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 <br /> Report Required For. POTW/WVVTP El RUSHsample Receipt Terym C <br /> Other submittal for ° <br /> e W � Cooler ID(s <br /> Special Report Formats—ELI must be notified ..o W ° a F additional charges <br /> prior to sample submittal for the following: .> o o � t and schedulingCustody eal <br /> NELAC❑ A2LA❑ Level IV❑ o y a p o 'o c Comments: Y <br /> N <br /> a <br /> Other a $ gg,A Schedule Code : <br /> Intact <br /> EDD/EDT Format Jz N a g 12 SW CODE 11 Y N <br /> 78 � 00 EroE i Table 1 Signature <br /> SAMPLE B 2 i° Z Frequency)1, Y/N <br /> IDENTIFICATION Collection Collection 610" J �, <br /> o s Match LAB ID <br /> (Name, Location, Date Time N F Y/N <br /> Interval etc) MATRIX > <br /> ' SW AWD 7/23/14 9:00 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ >- <br /> 2 SW BPL 7123114 8:45 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ Z <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ I <br /> 14{J <br /> 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ik <br /> CD <br /> 6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ a �. <br /> 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 01 m <br /> met <br /> g ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Custody Relinquished by: Bob Tennant Date/Time:7/23/14 16:30 Shipped by: FedEx Received by:CD <br /> Date/Time: <br /> Record Relinquished by: Date/Time: Shipped by: Received by: Datemme: ' <br /> MUST be LABOFWTORY USE ONLY <br /> O0 Signed Sample Disposal: Return to Client❑ Lab Disposal® Sample T #of fractions <br />