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A <br />o <br />J <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 3730 6298 <br />DATE: 3/27/15 SSTR S28168,S28169 <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 />ANALYSIS <br />Fe,.QttEs <br />T t=o <br />Notify ELI prior to <br />Report Required For: POTW/ WVfP ❑ <br />RUSH sample <br />R i t jempC <br />L <br />Other <br />submittal for <br />Special Report Formats — ELI must be notified <br />.. o <br />a additional charges <br />Co ler ID s <br />prior to sample submittal for the following: <br />m <br />t and scheduling <br />Comments: <br />NELAC ❑ A2LA El Level IV ❑ <br />a� <br />o <br />Custody al <br />Other <br />EDD/EDT [] Format <br />a3_ <br />` <br />o <br />SBA Schedule Code: <br />Y /C J <br />Intact <br />z <br />n <br />€ <br />z <br />GW CODE: <br />Y / N <br />Signature <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Z <br />Fre en <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />m <br />~ <br />Y / N <br />Interval, etc <br />MATRIX <br />' MW 6 <br />327/15 <br />13:00 <br />Water 3 <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />rEl <br />❑ <br />See attached <br />y- <br />2 MW 7 <br />3/27/15 <br />14:10 <br />Water 3 <br />® <br />❑ <br />❑ <br />CO <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />See attached <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />1 <br />UJI <br />` <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />s <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑❑ <br />❑ <br />❑ <br />❑ <br />E01❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o1 <br />o <br />cc <br />6 <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />9 <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑❑ <br />❑ <br />ofiEdl10 <br />❑ <br />❑ <br />❑❑0 <br />❑ <br />❑ <br />❑ <br />❑0 <br />❑ <br />Custody <br />Relinquished : Bob Tennant Dateliime:3127/15 16:30 <br />Shipped <br />by: FedEx <br />Received by4 4KyDate/Time <br />1p , <br />Record <br />Relinquished by: Date/Time: Shipped by: <br />Received by: Date/Time: <br />MUST be <br />Signed <br />Sample Disposal: Retum to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sam le T # of fractions <br />