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0 <br />v <br />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. 7732 2709 9193 <br />DATE: 3/26/15 SSTF: S28160,S28161,S28166 <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 />aNALY$15 <br />r.tOUFSTEo <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For: POTW/WVVrP ❑ <br />RUSH sample <br />�+I---� C <br />Other <br />e <br />F <br />submittal for <br />Special Report Formats — ELI must be notified <br />U <br />F <br />f= additional charges <br />Cooler <br />LU <br />prior to sample submittal for the following: <br />o rm m <br />s <br />� and schedulin <br />Custody al <br />'g <br />Comments: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />" �', a <br />o <br />Other <br />��3a� <br />� <br />Q <br />Y / <br />EDD/EDT ❑ Format <br />E a s <br />F <br />S&A Schedule Code : <br />Intact <br />GW CODE: <br />Y / N <br />$ <br />N <br />€ <br />Signature <br />SAMPLE <br />z <br />Y / N <br />IDENTIFICATION <br />Collection <br />Collection <br />Q'�' <br />F uenc : <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />< <br />Y!N <br />Interval, etc) <br />MATRIX <br />+ MW 15 <br />3/26/15 <br />11:15 <br />Water 3 <br />N <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />See attached <br />2 MW 17 <br />3/26115 <br />13:00 <br />Water 3 <br />N <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />El <br />N <br />❑ <br />See attached <br />3 MW 18 <br />3/26/15 <br />14:30 <br />Water 3 <br />N <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />N <br />171 <br />See attached <br />LU <br />- <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 />1 <br />t� <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />!-- <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />8 <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 />+� <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Date/Time:3/26/15 <br />16:30 <br />EShipped by: FedEx <br />Received b Date/Time: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received b DatefTime-- <br />MUST be <br />Signed <br />Semple Disposal: Return to Client ❑ Lab Disposal ® <br />LABO RY USE ONLY <br />Sam le T # of fractions <br />