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co <br />AEF 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. 7739 6171 9708 <br />DATE: 7/01/15 SSTF: S279755 <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. POTWNUWTP ❑ <br />ANALYSIS <br />REQUE <br />TLO <br />Notify ELI prior to <br />RUSH sample <br />Ree ` emp <br />Other <br />e i <br />P <br />submittal for <br />' ' C <br />Special Report Formats — ELI must be notified <br />to . a <br />a <br />F additional charges <br />Cooler ) <br />1131x <br />prior to sample submittal for the following - <br />t and scheduling <br />C1� <br />NELAC ❑ A2LA ❑ Level IV ❑ <br />Ito <br />2 Comments: <br />Custod I <br />Other <br />EDD/EDT ❑ Format <br />E 3 <br />E <br />— ~ <br />o <br />E S&A Schedule Code <br />Intact <br />z <br />a <br />0 <br />Z <br />F GW CODE: <br />= <br />Y ! N <br />Signature <br />Y/ N <br />SAMPLE <br />IDENTIFICATION <br />Collection <br />Collection <br />W <br />►- <br />u, <br />n Fr u <br />Match LAB ID <br />(Name, Location, <br />Date <br />Time <br />0 <br />� <br />to <br />Y / N <br />Interval, etc <br />MATRIX <br />Mine Refill <br />7/01/15 <br />12:30 <br />Water 4 <br />0 <br />® <br />❑ <br />0 ❑ <br />1 ® <br />❑ <br />1 ❑ <br />1 ❑ <br />O <br />® <br />❑ <br />See attached <br />?- <br />2 <br />0 <br />0 <br />0 <br />0 0 <br />❑❑❑❑ <br />0 <br />0 <br />0 <br />01-�Oocf <br />^ <br />0 <br />❑ <br />❑ <br />❑ 0 <br />0 <br />❑ <br />0 <br />0 <br />0 <br />OA <br />❑ <br />4u <br />` <br />❑ <br />❑ <br />❑ <br />❑ 0 <br />❑ <br />❑ <br />0 <br />❑ <br />D <br />❑ <br />❑ <br />5 <br />0 <br />❑ <br />❑ <br />❑ 0 <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />0101 <br />f <br />5 <br />0 <br />❑ <br />❑ <br />❑ ❑ <br />0 <br />0 <br />❑ <br />0 <br />0 <br />❑ <br />❑ <br />tl-� <br />7 <br />D <br />❑ <br />❑ <br />❑ ❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />0101 <br />+� <br />a <br />❑ <br />0 <br />0 1 <br />1000 <br />0❑ <br />010 <br />0 <br />Ax <br />s <br />❑ <br />❑ <br />0 <br />0 ❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ 1— <br />io <br />❑ <br />❑ <br />1 D 1 <br />❑ ❑ <br />❑ 1 <br />C1,01 <br />❑ <br />❑ <br />❑ <br />❑ <br />Custody <br />Relinquished b :Bob Tennant DatelTime:7/0111516:30 <br />Shi <br />: <br />FedEx <br />Received by: Date/Time: <br />Record <br />Relinquistred by: Date/Time: Shipped by: <br />Received by: Date/Tmie:a(ZI/S if: <br />MUST be <br />Signed <br />Sample Disposal: Retum to Client ❑ Lab Disposal 0 <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />