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CD <br />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 <br />Project Name: Schwartz - <br />Tracking No.7711 7424 9415 <br />DATE: 9/18/14 SSTF: S27663 <br />Report Mail Address: <br />Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill <br />Contact Name: Frank Adamic <br />1- 303 -842 -3893 mine phone <br />PO Box 1750; Canon City, CO 81215 -1750 <br />Voice: 1- 719 - 275 -7413 ext. 204 <br />Bob Tennant 1- 719- 371- 3009 -Cell <br />Invoice Address: <br />Invoice Contact: JoAnne Ary <br />Purchase Order #: <br />ELI Quote #: <br />PO Box 1750 <br />Tel: 1- 719- 275 -7413 ext. 209 <br />Canon City, CO 81215 -1750 <br />Fax: 1 -719- 275 -1669 <br />ANALYSIS <br />REOUES <br />T ED <br />Notify ELI prior to <br />Recgjpt T <br />Report Required For: POTWNWIiTP ❑ <br />RUSK sample <br />d C <br />Other <br />Special Report Formats — ELI must be notified <br />S <br />s <br />submittal for <br />additional <br />r ID(s <br />submittal for the foNong: <br />to wi <br />e <br />$ <br />i= charges <br />t <br />prior sample <br />�'� <br />and scheduli <br />NrC C] A2LA ❑ Level IV ❑ <br />s <br />g <br />5 <br />Comments: <br />I <br />Y / <br />EDD /EDT [I Format <br />' <br />E <br />e <br />WA Schedule Code: <br />Intact <br />t <br />t <br />N <br />z <br />GW CODE: <br />Y/ N <br />Signature <br />Y / N <br />SAMPLE <br />IDENCATION <br />Collen <br />Collection <br />F <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />` <br />Y ! N <br />Interval, etc <br />MATRIX <br />' Mine Refill <br />9/18/14 <br />8:00 <br />Water 5 <br />❑ <br />® <br />® <br />® <br />010 <br />❑ <br />Q <br />❑ <br />❑ <br />® <br />❑ <br />Table 4 <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />kLApq OLSq <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />e <br />❑ <br />010.0 <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />ii! "-- <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />© <br />❑ <br />❑ <br />a <br />[3 <br />0 <br />❑ <br />13 <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />co <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />13 <br />[3 <br />,a <br />❑ <br />❑ <br />11 <br />❑ <br />❑ <br />❑ 10 <br />101 <br />❑ 1 <br />❑ <br />❑ <br />Custody <br />Relinquished T <br />Date/Tim9 /18/1418:30 <br />Shipped <br />by, <br />FedEx <br />Received by- . DatelTime: <br />Record <br />Relinquished by: DateMme: <br />Shipped by. <br />Received by: ate ime: _ G <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABO RUORYUSEONLY <br />Samph T pe of fractions <br />