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ABU 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 Z <br />company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No.7711 1275 6743 1 DATE: 9110114 SSTF: 527680, 627681 <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81 21 5 -1 750 <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215 -1750 <br />Report Required For POTWMIWrP ❑ <br />Other <br />Special Report Formats — ELI must be notified <br />submittal the following: NELAC [I 42LAI Level IV <br />Other <br />EDD/EDT ❑ Format <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />'MW 14 <br />2 MW 15 <br />3 <br />4 <br />5 <br />6 <br />4 <br />,o <br />CD <br />N <br />0 <br />N <br />Collection I Cofechon <br />Date Time <br />9110114 11:45 <br />9/10P4 13:15 <br />Contact Name: Frank Adamic <br />Voice: 1- 719- 275 -7413 ext. 204 <br />Tel: 1 -719- 275 -7413 e)t. 209 <br />Fax: 1-719-275-1669 <br />ANALYSIS REQUESTED <br />1- 303 - 642 -3893 mine phone <br />Bob Tennant 1 -719- 371 - 3009 -cell <br />Purchase Order* I ELI Quote *: <br />Notify ELI prior to <br />RUSH sample <br />P <br />3MMOKOMPT-py <br />submittal for <br />a <br />additional charges <br />g <br />t <br />and scheduling <br />g <br />Comments: <br />ammo <br />E <br />$&A Schedule Code: <br />12 <br />o <br />GW CODE: <br />__ <br />x <br />mmmom <br />F vaimm <br />a`rIA <br />a00000m <br />°00000M <br />°00000m <br />°00000M <br />�000000 <br />�000000 <br />_00000E <br />_00000E <br />�000000 <br />■000000 <br />�000000 <br />�000000 <br />■nnnnen <br />1- 303 - 642 -3893 mine phone <br />Bob Tennant 1 -719- 371 - 3009 -cell <br />Purchase Order* I ELI Quote *: <br />UQOQQQ <br />Notify ELI prior to <br />RUSH sample <br />P <br />3MMOKOMPT-py <br />submittal for <br />a <br />additional charges <br />g <br />t <br />and scheduling <br />g <br />Comments: <br />ammo <br />E <br />$&A Schedule Code: <br />12 <br />o <br />GW CODE: <br />__ <br />x <br />mmmom <br />F vaimm <br />UQOQQQ <br />3MMOKOMPT-py <br />3MMMMOM <br />ammo <br />o <br />o <br />__ <br />a <br />mmmom <br />a`rIA <br />a00000m <br />°00000M <br />°00000m <br />°00000M <br />wennnn� <br />Rep <br />°C <br />C,ppler ID(s) L <br />Custody�l <br />YI <br />Intact <br />YIN <br />Signature <br />YIN <br />Match LAB ID <br />YIN <br />Custody Kai sc,ea py: CW 1 arind"t LMUM I Imm IW 1ti I0.ou %xioppW u . reur-A I r%euiwv v . LOOM I OHM <br />Record Relinquished by: DateTme: Shipped by: Received by: Date/Time: <br />MUST be LABO TRY USE ONLY <br />Signed Sample Disposal: Return to Client El Lab Disposal 0 Sample T 4 of fractions <br />