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v <br />CD <br />CD <br />N <br />0 <br />0 <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. 7733 6699 2035 <br />DATE: 4/14/15 SSTF: S27854,S27857 <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 />ANAL <br />YSIS <br />aEaUIESTE <br />: <br />Notify ELI prior to <br />Receipt Temp <br />Report Required For: POTWNWWTP ❑ <br />RUSH sample <br />C <br />Other <br />P <br />F <br />submittal for <br />-tea <br />Special Report Formats — ELI must be noted <br />= .. g <br />a <br />a <br />F additional charges <br />Coo r ID(F) <br />prior to sample submittal for the following: <br />„� <br />and schedulingd� <br />NELAC ElA2LA ElLevel IV E]a <br />; <br />o <br />Cust Y 9eal <br />Comments: <br />Other <br />3 <br />o <br />EDD/EDT ❑ Format <br />`a <br />E <br />S&A Schedule Code : <br />Intact <br />€ <br />3 <br />N <br />GW CODE: <br />Y / N <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />Q10� <br />m <br />Z <br />Fre u� <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />Y / N <br />Interval, etc) <br />MATRIX <br />~ <br />MW 20 <br />4/14/15 <br />11:00 <br />Water 3 <br />® <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />® <br />❑ <br />See attached <br />>_ <br />2 MW 19 <br />4/14115 <br />12:30 <br />Water 3 <br />o <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o <br />❑ <br />See attached <br />3 <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 />10 <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0101 <br />ae <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 1 <br />❑ <br />' <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />oe, <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished by: Bob Tennant Date/Time:4/14/15 16:30 <br />Ship <br />ed by: FedEx <br />Received b :_ Date/Time: <br />Relinquished by: Date/Time: <br />_ <br />Shipped by: <br />Received by:-Tj� Date/Time: 115 - <br />Record <br />MUST be <br />Signed <br />sample Disposal: Return to Client ❑ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type of fractions <br />