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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 Project Name: Schwartz- <br /> Tracking No 7713 4777 4021 DATE:10/08/14 SSTF:SV707, S27708 <br /> Report Mail Address: Sampler Name if other than Contact: <br /> Cotter Corporation-Canon City MIN Contact Name:Frank Adamic 1-W&.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 t ELI Quote 0: <br /> PO Box 1750 Tel: 1-719-275-7413 exL 209 <br /> Canon City,CO 81216-1750 Fax: 1-719-275-1669 <br /> ANALYSIS REQUESTED Notify ELI prior to Receipt Temp <br /> Report Required For. POTW/WVIrfP(:1RUSH sam 4.8 "C <br /> Other submittal for <br /> < Cooler ID(s) <br /> Special Report formats—ELI must be notified o � t � additional charges <br /> prior to sample submittal for the following: i$ c 8 t: and schedulingCustody-Seal <br /> Other � � <br /> � <br /> NELAC❑ A2LA❑ Level IV❑ Q Comments: Y <br /> EDD/EDT❑Format $ I S&A Schedule Code: Intact <br /> c �_ I <br /> SW CODE 11 Y/N <br /> SAMPLE Table 1 Signature <br /> IDENTIFICATION Collection Collection Frequency 1, Y/N <br /> rc <br /> MaWh LAB ID <br /> (Name,Location, Date Time /LN <br /> Interval etc MATRIX of <br /> SW AWD 10/08M4 8.00 Weller 1 ® ❑ ❑ ❑ D ❑ ❑ ❑ O 10 ® ❑ - <br /> 2 SIN SPL 10/08/14 8:30 Water 1 ® ❑ ❑ ❑ ❑ ❑ ❑ 0 ❑ ❑ ® ❑ <br /> 3 ❑ ❑ ❑ O ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ W <br /> 4 ❑ ❑ 10 ❑ ❑ D ❑ ❑ ❑ ❑ D 10 <br /> 5 ❑ D 113 ❑ o 10 ❑ ❑ ❑ ❑ ❑ ❑ >- <br /> 6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑ �. <br /> 7 1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 10 ❑ o ❑ <br /> s 1 1 ❑ ❑ ❑ ❑ 113 ❑ ❑ ❑ ❑ ❑ ❑ _01 m <br /> 9 ❑ ❑ ❑ ❑ 10 O ❑ ❑ O 10 O ❑ --� <br /> 10 ❑ ❑ ❑ ❑ 10 ❑ ❑ D ❑ D ❑ ❑ <br /> Custody Relinquished by.Bob Tennant Date/Ti nw.10/0811416:30 Shipped by: FedEx Received by: Date/Time: <br /> Record MUST Relinquished by: Date/Time: Shipped by: Received by:� DaWrIme:IvlQl 1,4 Ll <br /> MU be <br /> p LABORATORY t1S Signed Sample Disposal: Return to Client❑ Lab Disposal® Sam S of ONLY <br />