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CD <br />CD <br />0) <br />O <br />00 <br />CAJWustody and Analytical Request Record <br />PLEASE PRINT, provide as much Information as possible. ReW to corresponding notes on reverse side. Page 1 of 1 <br />Company Name: Cotter Corporation <br />Project Name: Schwartz - <br />Tracking No 7712 1421 2070 <br />DATE:9124114 SSTF: $27703, 327704 <br />Report Mail Address: <br />Sampler Name if other than Conted: <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 t <br />PO Box 1750 <br />Tel: 1-719-275-7413 exL 209 <br />Canon City, CO 81215 -1750 <br />Fax: 1 -719- 275 -1669 <br />Report Required For POTWNVWTP ❑ <br />ANALYSIS <br />REQUESTEC= <br />Notify ELI prior to <br />RUSH sample <br />Receipt Temp <br />Other <br />Special Report Formats - ELI must be notified <br />to sample submittal for the following: <br />o <br />m <br />submittal for <br />i additional charges <br />LA A C <br />Cooler ID(s) <br />prior <br />w <br />and scheduling <br />- <br />Custody <br />NELAC A2LA ❑ Level N [J <br />Other <br />s 3: <br />Comments: <br />Y /� <br />< <br />EDD/EDT [] Format <br />i- <br />S&A Schedule Code: <br />Intact <br />Z <br />0 <br />V <br />46 <br />z <br />SW CODE 11 <br />x Table 1 <br />Frequency 1, <br />Y /-W <br />Signature <br />y/1- <br />IDENTIFICATION CATION <br />Collection <br />Collection <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Interval etc ) <br />MATRIX <br />'' <br />Y /-11— <br />1 SW AWD <br />9124/14 <br />8:00 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />® <br />❑ <br />y. <br />2 SW BPL <br />924/14 <br />8:30 <br />Waler 1 <br />® <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />r'C <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />—0-] <br />iw <br />4 <br />❑ <br />❑ <br />❑ 10 <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />g <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 10 <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />ion <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 10 <br />❑ <br />❑ <br />❑ <br />❑ <br />c3F <br />Y <br />❑ <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />..., <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />tRl:� <br />❑ <br />❑ <br />❑ <br />E <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Date1Tsme:9/24 /1416:30 <br />Shipped by: FedEx <br />Received by: DaWrime: <br />Record MUST be <br />ReNnquWhed by: DateTme: <br />Shipped by: <br />Received by:JQ DaWrime9 196114 y <br />Signed <br />Sample Disposal: Retum to CIieM Lab Disposal <br />LABORATORY USE ONLY <br />Sample T # of fractions <br />