2015-08-21_HYDROLOGY - M1977300

• Permit No: M1977300
• IBM Index Class Name: HYDROLOGY
• Doc Date: 8/21/2015
• Doc Name: Water Quality/Mine Level Measurements, May 2015
• From: Cotter
• To: DRMS
• Email Name: MAC
• Media Type: D
• Archive: No

W
O
W
Chain of Custody and Analytical Request Record
PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1
Company Name: Cotter Corporation
Project Name: Schwartz -
Tracking No. 7735 0738 8569
DATE: 511/15 SSTF: S27887
Report Mail Address:
Sampler Name if other than Contact:
Cotter Corporation - Canon City Mill
Contact Name: Frank Adamic
1-303-642-3893 mine phone
PO Box 1750; Canon City, CO 81215-1750
Voice: 1-719-275-7413 ext. 204
Bob Tennant 1 -719 -371 -3009 -cell
Invoice Address:
Invoice Contact: JoAnne Ary
Purchase Order #:
ELI Quote #:
PO Box 1750
Tel: [phone] ext. 209
Canon City, CO 81215-1750
Fax: [phone]
ANALYSIS
REQUESTED
Notify ELI prior t0
Report Required For: POTWMIWTP F1
a
RUSH sample
Receipt Temp
�•11 o C
Other
r
F
submittal for
Special Report Formats — ELI must be notified
. _ o
a additional charges
Cooler ID(s)
prior to sample submittal for the following:
8m
'
`
t and schedulin
C
Comments:
NELAC ❑ A2LA ❑ Level IV ❑
$ QN s
a
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Custody�al
Other
EDD/EDT ❑ Format
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2
S&A Schedule Code:
Intact
Z
X1°01
N
r°-
Q
N
�'
N
GW CODE:
Y / N
Signature
Y / N
SAMPLEi
IDENTIFICATION
Collection
Collection
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Match LAB ID
(Name, Location,
Date
Time
o
o
W
m
<
Y / N
Interval, etc)
MATRIX
~
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~
' Mine Refill
511/15
9:45
Water 4
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Custody
Relinquished by:Bob Tennant Date/Tme:5/1/15 16:30
Shipped
by:
FedEx
Received by: Date/Time:
Record
Relinquished by: Date/Time:
Shipped by:
Received b Date/Time: t
MUST be
Signed
Sample Disposal: Return to Client ❑ Lab Disposal ®
LABOR T RY USE ONLY
Sample Type # of fractions