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AEFChain 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 7739 4401 <br />DATE: 1/30115 SSTF: S28127, 528129 <br />Report Mail Address: <br />Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill <br />Contact Name: Frank Ademic <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 exL 209 <br />Canon City, CO 81215 -1750 <br />Fax: 1 -719 -275 -1669 <br />Notify ELI prior to <br />Receipt p <br />El Required For: POiWMIWTP <br />RUSH sample <br />C <br />Other <br />Special Report Formats — ELI must be notified <br />Vol o <br />t <br />submittal <br />dditio a! for <br />a additional charges <br />Cc lA <br />C <br />prior to sample submittal for the following: <br />w <br />and scttedulin <br />CustodyXeal <br />Comments: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />Y / <br />Other <br />EDD/EDT C] Format <br />3 <br />E -C <br />! <br />~ <br />E <br />S&A Schedule Code: <br />intact <br />Y 1 N Nfir <br />Z <br />W <br />z <br />= <br />c <br />GW CODE: <br />Signature <br />YIN <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Frequency: <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />< <br />YIN <br />Interval, etc ) <br />MATRIX <br />" <br />MW-19 <br />1129115 <br />13:30 <br />Water 3 <br />® <br />❑ <br />❑ <br />❑ <br />1 D <br />❑ <br />❑ <br />❑ <br />O <br />1 ❑ <br />® <br />D <br />See attached <br />� <br />s Domestic Well <br />IM14 <br />13:00 <br />Water 3 <br />® <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />D <br />❑ <br />® <br />D <br />See attached <br />3 <br />D <br />❑ <br />❑ <br />01010 <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />=.a <br />s <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />- <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />D 1 <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />D <br />❑ <br />10 <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />�2Go <br />Custody <br />Relinquished . Tennant Datelrime:1/30/15 16:30 <br />Shipped <br />by: FedEx <br />vv- d. <br />Received b : DtfTi <br />: <br />Record <br />Relinquished by: Date/Time: <br />I Shipped by: <br />Received by: Daterrime:24 '7 105 <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample T * of fractions <br />0< <br />