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CD <br />Company Name: Cotter Corporation Project Name: Schwartz - <br />Tracking No.771 0 4883 8219 DATE: 9/04/14 SSTF: 627662 <br />Report Mail Address: Sampler Name if other than Contact <br />Cotter Corporation - Canon City Mill Contact Name: Frank Adamic 1- 303 -642 -3893 mine phone <br />PO Box 1750: Canon City, CO 81215 -1750 voice: 1- 719 - 275 -7413 ext. 204 Bob Tennant 1- 719 - 371 - 3009 -cell <br />Invoice Address: Invoice Contact: JoAnne Ary Purchase Order 0: ELI Quote t. <br />PO Box 1750 Tel: 1-719-275-7413 ext. 209 <br />Canon City, CO 81215 -1750 Fax: 1- 719 -275 -1669 <br />ANALYSIS REQUESTED Notify ELI prior to Receipt T�p <br />Report Required For: POTWMIWrP ❑ RUSH sample C.J <br />Other submittal for ' C <br />Special Report Formats — ELI must be notified a F additional charges C ID(s) <br />prior to sample submittal for the following: F <br />�� � t and scheduling <br />NEL C [I A2LA [I Level IV [I .. Comments: Custody <br />EDD /EDT [I Format ` t F E SBA Schedule Code: Intact <br />: t t _ F GW CODE: YIN <br />SAMPLE r Signature <br />IDENTIFICATION Collection Collection �y c� amino ,�� + Y / N F Match LAB ID <br />(Name, Location, Date Time � <br />Interval, etc MATRIX Y / N <br />Mine Refill 91(/14 10:15 Water 5 1311919 ® ® ® ❑ ❑ 1 ❑ ❑ ® ❑ Table 4 !- <br />s ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ WI <br />❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O_ <br />a 8 g ❑ ❑ <br />❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 01 <br />❑ o ❑ ❑ ❑ o ❑ 01010 ❑ o <br />❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />❑ [3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ^� Oo.'m <br />NIX <br />❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br />CD <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 />G <br />c <br />.- <br />j r <br />,o <br />❑ <br />❑ <br />o <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Rem Bob IMMUt <br />Date/Tim9AW1416:30 <br />ShJ <br />by: FedEx <br />Received by, Datef <br />rime: <br />Record <br />ReNnquW%d by: Date/Time: <br />Shipped by: <br />Received b . Datefrime: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABO TORY USE ONLY <br />Sample Type 8 of fractans <br />