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AMUChain 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 <br />Project Name: Schwartz - <br />Tracking No. 7727 4675 9949 <br />DATE: 128115 SSTF: $2$069, $28()66, S28071 <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 -1750 <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 ext. 209 <br />Canon City, CO 81215 -1750 <br />Fax: 1 -719- 275 -1669 <br />A <br />,, Ss; <br />r? Esx0r::;•�:,,; <br />Notify ELI prior to <br />Reap <br />Report Required For. POTWMNYrP ❑ <br />RUSH sample <br />C <br />,ID(s) o <br />Other <br />Special Report Formats — ELI must be notified <br />.. c <br />submittal for <br />I additional charges <br />Coo <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />ate'' <br />F <br />9 <br />t and scheduling <br />Comments: <br />Custod�l <br />y <br />s <br />3 <br />t <br />e <br />Y N' <br />EODD/EDT ❑ Format <br />< <br />a <br />N <br />�' <br />t <br />4 <br />S&A Schedule Code: <br />�? GV1/ CODE: <br />x <br />Intact <br />Y I N <br />Signature <br />Y / N <br />SAMPLE <br />" <br />IDENTIFICATION <br />Collection <br />Collection <br />U, <br />°� <br />F <br />Match LAB ID <br />(Name, Location, <br />Date <br />Tune <br />~ <br />Y / N <br />Interval, etc ) <br />MATRIX <br />'' <br />' Mine Refill <br />1/28H4 <br />15:20 <br />water 1 <br />❑ <br />❑ <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />'Mine Refill <br />1128/15 <br />11:00 <br />Water 4 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />See attached <br />3 Mw 20 <br />128115 <br />13:24 <br />Water 3 <br />® <br />❑ 10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />See attached <br />4 <br />❑ <br />010,0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />d <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />62 <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />[3 <br />[1 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relirguls hed : Bob T <br />n Date/Tim128/1516:30 <br />Shi <br />: <br />FedEx <br />Received by: <br />ime: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by ate/Time: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORffORY USE ONLY <br />Sample Type v # of fractions <br />