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CD <br />a <br />co <br />C 117FAM stody and Analytical Request Record <br />PLEASE PRINT; provide as much information as possrble. Refer to corresponding notes on reverse side. Page 1 of 1 <br />Company Name: Cotter Corporation <br />Project Name: Schwartz - <br />Tracking No 7712 0087 6811 <br />DATE:9 118/14 SSTF: S27667, 527668 <br />Report Mail Address: <br />Sampler Name if other than Contact <br />Cotter Corporation - Canon City Mil <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 0: <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 />Report Required For. POTWNVWTP ❑ <br />ANALYSIS <br />tL'.2 <br />-'• <br />STED <br />Notify ELI to <br />RUSH sample <br />R iPt P <br />Other <br />2 <br />submittal for <br />o C <br />' <br />Special Report Formats - ELI must be notified <br />prior to sample submittal for the following:m <br />.. c <br />` additional charges <br />+~ and scheduling <br />f �D(s <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />15 M <br />Comments: <br />Custody <br />Other <br />EDD /EDT [] Format <br />< <br />' <br />� <br />F <br />S&A Schedule Code <br />Intact <br />1l <br />_ <br />f. SW CODE I I <br />'table 1 <br />Fre4Ue^� 1 <br />YIN <br />Signature <br />YIN <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Collection <br />Date <br />Collection <br />Time <br />a <br />Match LAB ID <br />Cr 6 7 � 6 <br />/ <br />Interval etc <br />MATRIX <br />t7 <br />SW AWD <br />9118/14 <br />10 :00 <br />Water 1 <br />® <br />13 10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />:.. <br />2 SW BPL <br />9118/14 <br />10:30 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />13 <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />® <br />❑ <br />3 <br />❑ <br />❑ <br />[3 <br />O <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />[3 <br />E03 <br />O <br />4 <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />O <br />E3 <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />8 <br />❑ <br />O <br />❑ <br />[03 <br />❑ <br />O <br />13 <br />O <br />[3 <br />❑ <br />O <br />01 <br />,x <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />D <br />❑ <br />s <br />❑ <br />1310 <br />❑ <br />❑ <br />E3 <br />10 <br />❑ <br />❑❑ <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />© <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />70 <br />O <br />01010 <br />❑ <br />O <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by @Ob Tennant DatelTme:9/1811416:30 <br />Shipped by: FedEx <br />Received by: -JAI Data/Time: .t -('I - <br />Record <br />MUST be <br />Relinquished by:. DatelTime: <br />Shipped by: <br />Received by: Date/Time: <br />Signed <br />Sample Disposal: Retum to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />