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v <br />CD <br />CD <br />N <br />W <br />0 <br />N <br />A <br />C ustody and Analytical Request Record t <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 30291932 <br />DATE:9/03 /14 SSTF: S27624 <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 4750 <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 <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. POTWMNYrP ❑ <br />Other <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />R pt m C <br />° <br />COO or I <br />Special Report Formats — ELI must be notified <br />to sample submittal for the following: <br />. G 1 <br />w <br />d additional charges <br />!� and scheduling <br />prior <br />NOEthe C ❑ a2LA p Level 11/ ❑ <br />cs <br />$ <br />g <br />g Comments: <br />Cusb sal <br />PC <br />; <br />�d�r <br />EDD/EDT [I Format <br />S 11 Code: <br />E 31N <br />Intact <br />-� <br />CODE <br />/ N� <br />a <br />Table 1 <br />Frequency t. <br />S re <br />N <br />SAMPLE <br />IDENTIFICATION <br />Colhx9on <br />Collection <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Y / N <br />Interval etc ) <br />MATRIX <br />' SW AWD <br />9/03114 <br />9:00 <br />Water 7 <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />2 <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 />W <br />4 <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 1 <br />❑ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />13 <br />13 <br />E3 <br />0 <br />❑ <br />❑ <br />♦. <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />m <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />11 10 <br />❑ <br />❑ <br />1:1 <br />El <br />_j <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />_0F0_[3. <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Date/Time:9/03/1416:30 <br />Shipped by: FedEx <br />Received by: YM Date/Time: <br />Record <br />Relinquished by: DatelTime: <br />Shipped by: <br />Received by: DaWTime: .0 <br />MUST be <br />Signed <br />Semple Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />