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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 />Tracking No 7746 5574 2536 <br />Project Name: Schwartz - <br />DATE:10/2/15, S28439 Th S28441 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />PO Box 1750; Canon City, CO 81215-1750 <br />Contact Name: Frank Adamic <br />Voice: 1-719-275-7413 ext. 204 <br />Sampler Name if other than Contact: <br />1-303-642-3893 mine phone <br />Bob Tennant 1 -719 -371 -3009 -cell <br />Invoice Address: <br />PO Box 1750 <br />Canon City, CO 81215-1750 <br />Invoice Contact: JoAnne Ary <br />Tel: 1-719-275-7413 ext. 209 <br />Fax: 1-719-275-1669 <br />Purchase Order #: <br />ELI Quote #: <br />Report Required For POTWNVWTP <br />Other <br />MI <br />K Number of Containers <br />AAWSV o <br />K r Other <br />73 Air. Water .ds, Yegor+, <br />»h..:.:_ :SIS REOM's, En <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />RUSH <br />submittal for <br />P additional charges <br />. and scheduling <br />Temp <br />-4 Z5 ' C <br />U - dissolved only - CODE 11 <br />U - total & dissolved - CODE #3 <br />Ra -226 total & dissolved CODE1113 <br />1 <br />r <br />Mer ID s) <br />�' 1 i <br />1 <br />Special <br />prior to sample <br />NELAC <br />Other <br />EDD/EDT <br />Report <br />■ <br />Formats – ELI must be notified <br />submittal for the following: <br />A2LA ❑ Level IV <br />0 Format <br />IN <br />Custody real <br />Y L:%' <br />Intact <br />Y / N <br />Signature <br />Y / N <br />Match LAB ID <br />YIN_—. <br />RUSH Turnaround <br />Comments: <br />S&A Schedule Code : <br />SW CODE II 1 <br />Table 1 <br />Frequency 1, <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />1 SW-AWD <br />10/2/15 <br />12:00 <br />Water 5 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />O <br />■ <br />0 See attached <br />2 SW -BPL <br />10/2/15 <br />13:45 <br />Water 5 <br />0 <br />0 <br />0 <br />® <br />0 <br />0 <br />■ <br />0 <br />■ <br />0 <br />® <br />0 See attached <br />3 <br />❑ <br />❑ <br />is <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />■ <br />0 111 <br />4 <br />00• <br />• <br />• <br />0.• <br />. <br />■ <br />D <br />■ <br />5 <br />❑ <br />■ <br />❑ <br />is <br />. <br />❑ <br />❑ <br />• <br />■ <br />is <br />■ <br />■ <br />>- <br />6 <br />■ <br />. <br />■ <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />■ <br />0 <br />■ <br />❑ <br />❑ <br />■❑ <br />o <br />0 <br />ft <br />7 <br />8 <br />❑ <br />. <br />. <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />lC <br />9 <br />• <br />00 <br />• <br />00 <br />• <br />0 <br />0 <br />• <br />0 <br />• <br />10 <br />000 <br />• <br />00 <br />• <br />0 <br />• <br />• <br />00 <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:10/2/1516:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by Date/Time:1015115 a:, <br />Sample Disposal: Return to Client 0 Lab Disposal <br />Qi <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />