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AMU 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 Project Name: Schwartz- <br /> Tracking No.771 3 4530 6686 DATE: 10/01/14 SSTF: s27710 <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#: ELI Cluote#: <br /> PO Box 1750 Tel: 1-719-275-7413 exL 209 <br /> Canon City,CO 81215-1750 Fax: 1-719-275-1669 <br /> ANALYSIS REQUESTED Notify ELI prior to <br /> Report Required For. POTWIWWTP❑ RUSH sample Race T�np <br /> Other submittal submittal for o C <br /> Cool <br /> Special Report Formats—ELI must be notified o� � < additional charges c-� r, <br /> prior to sample submittal for the following: m - !r and scheduling <br /> ►-> g Custody Seal <br /> NELAC El 's A2LA❑ Level IV H Comments: Y <br /> Other <br /> EDD/EDT El Format `� S&A Schedule Code: Intact <br /> z t t GW COt Y/N <br /> 2 Signature <br /> SAMPLE H Y/N <br /> a 4 <br /> IDENTIFICATION Collection Collection F u Match LAB ID <br /> (Name,Location, Date Time Y/N <br /> Interval,etc) MATRIX <br /> 'Mine Refill 10101/14 10:45 Water 5 O ® ® M ® ® ❑ ❑ ❑ ❑ ® D Table 4 5� <br /> z ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑ ❑ ❑ ❑ <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ RY <br /> 00 <br /> 4 ❑ ❑ o ❑ ❑ o o ❑ ❑ D D o a <br /> s ❑ ❑ ❑ a o ❑ ❑ 01010 ❑ ❑ <br /> ❑ 01010 ❑ ❑ ❑ 01010 ❑ ❑ >~ <br /> ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ D ❑ ❑ +� <br /> ❑ ❑ ❑ D ❑ ❑ o o ❑ o a ❑ ca <br /> 0 <br /> 9 ❑ ❑ ❑ 01010 ❑ ❑ ❑ ❑ ❑ D <br />'> >o 10 ❑ ❑ 1 D D D ❑ ❑ ❑ ❑ 1 ❑ D <br /> Custody Re1i wished :Bob T Date/Tim10/01/1416:30 SF-hipped b :FedEx Received b : Date/rime: <br /> Record Relinquished by: Date/7ime: Shipped by: Received by� Date/Time: <br /> ~ <br /> MUST be LAB TORY USE O L <br /> Signed Sample Disposal: Retum to Client❑ Lab Disposal 19 Sample Type #of fractions <br />