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v <br />cc <br />CD <br />N <br />O <br />4 <br />al <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.7710 9793 3090 <br />DATE: 9/04/14 SSTF: S27679 <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. 642 -3893 mine phone <br />PO Box 1750; Canon City, CO 81215 -1750 <br />Voice: 1- 719 - 275 -7413 wd, 204 <br />Bob Tennant 1- 719 -371- 3009 -cell <br />Invoice Address: <br />Invoice Contact: JoAnne Ary <br />Purchase Omer # <br />ELI Quote #: <br />PO Box 1750 <br />Tel: 1- 719- 276 -7413 ext. 209 <br />Canon City, CO 81215 -1750 <br />Fax: 1 -719- 275 -1669 <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For: POTWANWTP ❑ <br />RUSH sample <br />° C <br />Other <br />Special Report Formats - ELI must be notified <br />C <br />submittal for <br />F additional charges <br />�� IX <br />prior to sample submittal for the following: <br />NELAC ❑ A21A ❑ Level IV ❑ <br />m <br />y <br />$ <br />c <br />t and scheduling <br />Comments: <br />Custody Seal <br />_ <br />Y <br />Dl <br />EE EDT ❑Format <br />' <br />S&A Scheule Code : <br />Intact <br />Y 11N1- <br />t-- <br />GW CODE: <br />H <br />9 <br />0 <br />Z <br />Signature <br />IDENTIFICATION <br />Col�lec#ion <br />Collection <br />°C F <br />Match LABJD <br />(Name, Location, <br />F <br />$ <br />1 <br />I! <br />Y / M' <br />Interval, etc <br />MATRIX <br />' MW 13 <br />9/x9/14 <br />12A5 <br />Water 6 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />1 ❑ <br />O <br />1 ❑ <br />1 ❑ <br />91 <br />❑ <br />Table 2 <br />�- <br />2 <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />D <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />0101 <br />UJI <br />4 <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />S <br />❑ <br />❑ <br />❑ <br />D <br />D <br />❑ <br />D <br />D <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />sF-- <br />7 <br />❑ <br />D <br />❑ <br />D <br />❑ <br />❑ <br />D <br />01010 <br />❑ <br />❑ <br />ci_; <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0101 <br />a <br />D <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />D <br />1 <br />10 <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Ingul~ Tenn <br />DateTm9/09/1416:30 <br />Shipped <br />b : Fed Ex <br />Received Date/Time: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: ID Date1TIme:cI1I01p4cJ1,t <br />MUST be <br />Signed <br />Sample Disposal: Retum to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample T # of fractions <br />