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T <br />CD <br />0 <br />M <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. 7731 5799 4461 <br />DATE: 3/18/15 SSTF: S27837, 527838 <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 />RE00i-STEL <br />Notify ELI prior to <br />El Required For: POT NwvTP <br />RUSH sample <br />ReceiptTemp <br />2 ° <br />Other <br />F <br />submittal for <br />C <br />Special Report Formats - ELI must be notified <br />.. <br />additional charges <br />Cooler ID(s) <br />prior to sample submittal for the folk wing: <br />oF <br />8m 1 <br />and schedulin <br />CR iK* <br />Custody <br />g <br />Comments: <br />NELAC ElA21A El Level Level 1V <br />$ � n y <br />o <br />Seal <br />Y /© <br />Other <br />EDD/EDT ❑ Format <br />3 a <br />`�+ <br />? <br />SBA Schedule Code: <br />Intact <br />z <br />�'' <br />N <br />€ <br />3 <br />z <br />GW CODE: <br />Y / N <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />mFr <br />a <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />� <br />Y / N <br />Interval, etc <br />MATRIX <br />'- <br />Sump 4 <br />3/17/15 <br />8:30 <br />Water 3 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />See attached <br />2 Sump 1 <br />3/17/15 <br />13:30 <br />Water 3 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />J0D <br />❑ <br />See attached <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />El <br />❑ <br />❑ <br />LLI <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />>tY <br />6 <br />❑ <br />❑❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />�... <br />7 <br />11 <br />11 <br />❑ <br />❑ <br />11 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />11a <br />11 <br />❑ <br />1:11❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 1 <br />❑ <br />❑ <br />❑ <br />10 <br />❑❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Date(rime:3/18/15 16:30 <br />Shipped <br />b : FedEx <br />- <br />Received by: DatefTime: <br />Record <br />Relinquished by: Date/Time: Shipped by: <br />Received bye#Lk Date/Time: Q (SOq: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ❑ Lab Disposal <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />