Laserfiche WebLink
v <br />cc <br />CD <br />N <br />V <br />0 <br />N <br />C ustody 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 3094 5634 <br />DATE:9/03/14 SSTF: S276251 S27660 <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 if: <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 POTWNWVTP [] <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />RUSK sample <br />Receipt�emp <br />Or <br />the <br />Special Report Formats - ELI must be notified <br />i <br />submittal for <br />& ---' C <br />C or ID(s) <br />prior to sample submittal for the following: <br />c <br />A M � <br />� <br />� <br />� <br />� <br />it additional charges <br />t <br />� `p � <br />and schedulin <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />is <br />g Comments: <br />Custody Seal <br />Other <br />3 <br />` <br />Y / N <br />intact <br />EDD /EDT [_-] Formed <br />2' <br />S8A Schedule Code: <br />.s <br />SW CODE I 1 <br />Table 1 <br />Y / N <br />Signature <br />SAMPLE <br />IDENTIFICATION <br />Frequencya 1, <br />Y / N <br />(Name, Location, <br />Date <br />Time <br />Match LAB ID <br />Interval etc ) <br />MATRIX <br />' <br />Y / N <br />' SW WL <br />9103114 <br />10:00 <br />Water 7 <br />❑ <br />❑ <br />❑ <br />1 ® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />�.. <br />2 SW FBRG <br />9/03114 <br />11,45 <br />Water 3 <br />❑ <br />® <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />ea, <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 1 <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />t3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />F. <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />E3 <br />❑ <br />❑ <br />El <br />13 <br />[3 <br />❑ <br />❑ <br />oc <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />CDP <br />co <br />9 <br />❑ <br />❑ <br />❑ ,0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />11 <br />—J <br />10 <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennanj DaterTime :9/03/14 16:30 <br />Shipped by: FedEx <br />Received by`� Dat&Time: q ; 5 C) <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: Dat& Time: G- <br />MUST be <br />Signed <br />Return Disposal: Retu to Client ❑ Lab Disposal ® -1 <br />LABORATORY USE ONLY <br />;:mple <br />Type # of fractions <br />