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Chain 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. 7725 8504 4927 <br />DATE: 1114/15 SSTF: S28103, S28106,S28107 <br />Report Mail Address: <br />Sampler Name if other than Contact <br />Cotter Corporation - Canon City Mill <br />Contact Name: Franc 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 IP 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 />ANACYSiS <br />REOU <br />-s <br />O <br />Notify ELI prior to <br />ReceiptT mp <br />Report Required For POTWMNWTP ❑ <br />RUSH sample <br />submittal for <br />G Al , C <br />Other <br />Special Report Formats — ELI must be notified <br />a <br />.. c <br />F additional charges <br />Cooler l0(s) <br />prior b sample submittal for the following: <br />; <br />and scheduling <br />Cu y Seal <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />e <br />Comments: <br />YIN <br />E EDT Format <br />D J <br />c <br />.. <br />is <br />S&A Schedule Code: <br />W CODE: <br />Intact <br />Y / N <br />Z <br />z <br />Signature <br />YIN <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Fre uenc <br />atch LAB ID <br />Match <br />(Name, Location, <br />Date <br />Time <br />A <br />I <br />YIN <br />Interval, etc <br />MATRIX <br />MW 00 <br />1114114 <br />11;30 <br />Water 3 <br />® <br />❑ <br />❑ <br />❑ <br />E3 <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />[1 <br />see attached <br />2 MW 9 <br />1114115 <br />14:00 <br />Water 3 <br />® <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />See attached <br />3 SUMP 9 <br />1/14115 <br />15;15 <br />Water 3 <br />® <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />See ached <br />❑ <br />01010 <br />❑ <br />❑ <br />10 <br />❑ <br />10 <br />10 <br />❑ <br />❑ <br />5 <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />r <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />w,. <br />,o <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />[3 <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished : Tennant Date/Timl /14/1516:30 <br />Shipped by: FedEx <br />Received by: Date/rime: <br />Record <br />Relinquished by: Date/ 1me: <br />Shipped by: <br />Received b <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABO ORY USE ONLY <br />Sample Type 8 of fractions <br />E <br />�h <br />