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C ustody and Analytical Request Record <br /> ANVPLEASE 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 7713 45N 3174 DATE:10/01/14 SSTF: S27708 <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 Quote#: <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 Rece t T <br /> Report Required For. POTWANWTP❑ RUSH sample p <br /> 1" 1 ,C <br /> Other submittal for C ID(s) <br /> Special Report Formats—ELI must be notified . c t additional charges <br /> prior to sample submittal for the following: m m c� t and scheduling <br /> Sep <br /> NOEELLArC❑ A2LA[I Level IV❑ 13~1C* <br /> 8 v Comments: Custod/tl <br /> < <br /> Intact <br /> EDDlEDT[]Format A CODE� ��' Y/N <br /> y <br /> SAMPLE Table 1 Signature <br /> IDENTIFICATION Coll Colection , z Frequencyl1, Match LAB 10 <br /> (Name,Location, > F Y/N <br /> Interval,etc) MATRIX :1 <br /> ❑ ❑ ❑ ❑ ❑ o 1 ❑ ❑ o 1 ❑ ❑ ❑ �. <br /> 2 SW BPL 10/01/14 9150 Water 1 ❑ O O ® ❑ O ❑ ❑ ❑ ❑ ® ❑ <br /> 3 O ❑ O ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ W <br /> 4 ❑ ❑ O ❑ O O ❑ ❑ O O ❑ ❑ <br /> 5 ❑ 01010 ❑ ❑ ❑ ❑ ❑ O O To. >" <br /> 7 ❑ 01010 O O ❑ ❑ ❑ O ❑ ❑ <br /> 8 ❑ 01010 ❑ ❑ ❑ ❑ ❑ O ❑ 131 00 <br /> s ❑ ❑ ❑ ❑ ❑ 010 ❑ ❑ ❑ ❑ ❑ —r <br /> +o ❑ ❑ ❑ O ❑ ❑ ❑ ❑ ❑ ❑ ❑ O <br /> 3 Custody Relinquished by:Bob Tennant Date/Time:10/01/1416:30 Shipped by: FedEx Received by: Date/Time: on <br /> Record Relinquished by, Date/Time: Shipped by: Received by: ate/Time: <br /> MUST be <br /> Signed Sample Disposal: Retum to Client❑ Lab Disposal® LA T RY USE ONLY <br /> Sam Tpe #of fractions <br />