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D <br />CD <br />OD <br />0 <br />00 <br />AurChain 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. 77281014 2136 <br />DATE: 213/15 SSTF: W 129 <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, 0081215 -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 />r,• -�,� <br />c. r' ;r, <br />..r : <br />_.��: <br />, .:,= <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For: POTW/WWTP ❑ <br />RUSH sample <br />C <br />Other <br />Special Report Formats - ELI must be notified <br />o <br />< <br />submittal for <br />p additional charges <br />Cooler 1D(s) <br />prior to sample submittal for the following: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />�'� <br />m <br />-g <br />and scheduling <br />g Comments: <br />Custody t <br />1 <br />Y <br />Otheri <br />EDD /EDT ❑ Format <br />E S8�A Cade <br />Intaci <br />Z <br />GW CODE: <br />Y / N <br />Signature <br />SAMPLE <br />;a <br />,;, <br />IDENTIFICATION <br />Collection <br />Collection <br />F <br />vim= <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Y / N <br />Interval, etc ) <br />MATRIX <br />❑ <br />D <br />D <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑• <br />2 Domestic well <br />21&14 <br />13:00 <br />Water 1 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />O <br />1 See attached <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />t3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑" <br />s <br />D <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />01010 <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />1 <br />--` <br />' <br />❑ <br />01010 <br />❑ <br />D <br />❑ <br />D <br />O <br />D <br />❑ <br />❑' <br />s <br />❑ <br />01010 <br />O <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />€ <br />B <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />•° <br />10 <br />❑ <br />❑ 10 <br />❑ <br />101 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Retie uished : Bob Tennant DaWrime:2/3 /15 16:30 <br />Shipped <br />by: FedEx <br />dLebuv4 <br />Received Date/Time: <br />Record <br />Relinquished by: DaWrime: <br />Shipped by: <br />Received bye Daternme: _ I S-- <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sam pie T # of fractions <br />