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0 <br />A <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: Schwarz - <br />Tracking No. 7734 2299 564 <br />DATE: 4/21/15 SSTF: S27905,S27908 <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 />Report Required For: POTWJWVIr'rP ❑ <br />� <br />ANALYSIS <br />REQUESTED <br />Notify ELI prior t0 <br />RUSH sample <br />Recei t Temp <br />�' „ <br />Other <br />Special Report Formats — ELI must be notified <br />m o S <br />submittal for <br />a additional charges <br />o C <br />[ 4 <br />Cooler ID(s <br />prior to sample submittal for the following: <br />Tm <br />b <br />v <br />and scheduling__ <br />Custod eal <br />g <br />Comments: <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />v', <br />o <br />Other <br />EDD/EDT ❑ Format <br />� � m <br />a <br />2 <br />� <br />E <br />S&A Schedule Code: <br />Y N <br />Intact <br />Z m <br />r <br />€ <br />= <br />GW CODE: <br />Y / N <br />Signature <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />��' <br />Fr uenc : <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />m <br />~ <br />Y / N <br />Interval, etc) <br />MATRIX <br />MW 1 <br />4/21/15 <br />11:30 <br />Water 3 <br />S <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />S <br />❑ <br />See attached <br />2 MW 0 <br />4121/15 <br />14:00 <br />Water 3 <br />S <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />S <br />D <br />See attached <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />01010 <br />❑ <br />❑ <br />❑ <br />C�®� 1 <br />UJ <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />.� <br />5 <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 />010. <br />�-- <br />' <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />o-�c <br />es <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />El <br />❑ <br />C1 <br />❑ <br />C1 <br />❑ <br />❑ <br />Cl <br />Cl <br />Custody <br />Relinquished by: Bob T nnan Date/Time:4/21/15 16:30 <br />Shipped <br />by: FedEx <br />Received by: I ( ateTme: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received ;by Date/TimetG- Io: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client 0 Lab Disposal ® <br />LB T RY USE ONLY <br />Sample T # of fractions <br />