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N <br />0 <br />N <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 1203 1334 <br />DATE: 3/25/15 SSTF: S278144,S28145 <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 Ord": <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 />ANALYSIS <br />REQUESTED <br />Notify ELI prior to <br />Report Required For: POTWNVWTP ❑ <br />� <br />RUSH sample <br />R i Tem <br />�pb p <br />° <br />Other <br />$ <br />submittal for <br />C <br />Special Report Formats — ELI must be notified <br />o $ <br />F <br />additional charges <br />Cop�r iD(�) <br />prior to sample submittal for the following: <br />�m n <br />and schedulingC <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />" m U) o <br />CustodySeal <br />r <br />Comments: <br />Other <br />E <br />ES&A <br />❑ Format <br />E a <br />E <br />Schedule Code: <br />Intact <br />Z 15)EDD/EDT <br />g <br />� <br />= <br />ttFrequency- <br />GW CODE: <br />Y / N <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />�°�' <br />z' <br />Fre ue <br />Match LAB !D <br />(Name, Location, <br />Date <br />Time <br />< <br />Y I N <br />Interval, etc) <br />MATRIX <br />MW 13 <br />3125/15 <br />9:50 <br />Water 3 <br />S <br />❑ 1 <br />❑ <br />1 ❑ <br />1 ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />S <br />❑ <br />See attached <br />�►- <br />2 MW 14 <br />3125/15 <br />10:40 <br />Water 3 <br />S <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />FO <br />❑ <br />See attachedell <br />Z <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />YJ <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 />�+ <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0101 <br />}� <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />010.0 <br />❑ <br />❑ <br />❑ <br />❑ <br />0-1 <br />Im <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />—� <br />,o <br />❑ <br />❑ <br />L1❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished : Bob Tennant Date/Time:3/25/15 16:30 <br />Shipped <br />b : FedEx <br />Received b : Date/Time: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: Date/Time:3�Zb�t5.VK <br />MUST be <br />Signed <br />Semple Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />