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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 8999 4700 <br />Project Name: Schwartz - <br />DATE:10/7/15, S28471 Th S28472 <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: POTW/WVIfTP 0 <br />Other <br />Number of Containers <br />Sample TYPe' <br />--I AWSVBO <br />X Air,tiater2olls Scads, Yegetallon, <br />X flioassay giber <br />Nr.L%OS RECPc.;E 4T!.: D <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittalioch forCoq�er <br />a P additional charges <br />t and scheduling <br />R ip emp <br />o C <br />U - dissolved only - CODE #1 <br />U - total & dissolved - CODE #3 <br />Ra -226 total & dissolved CODE#3 <br />Table 1 <br />I s)� <br />(i, <br />Special <br />prior to sample <br />NELAC <br />Other <br />EDD/EDT <br />Report <br />■ <br />Formats <br />submittal <br />A2LA <br />0 Format <br />— ELI must be notified <br />for the following: <br />■ Level IV 0 <br />Custody = = I <br />Y ti <br />Intact <br />Y/N <br />Signature <br />YIN <br />Match LAB ID <br />Y / N <br />RUSH Turnaround <br />Comments: <br />SM Schedule Code : <br />SWCODE I1 <br />Table I <br />Frequency! 1, <br />©t' cite Si2-i <br />ILS _ 1 --in <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />1 SW -GS <br />10/6/15 <br />14:45 <br />Water 5 <br />■ <br />0 <br />0 <br />® <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />O <br />See attached <br />2 SW-FBRG <br />10!7/15 <br />13:25 <br />Water 5 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />■ <br />■ <br />® <br />■ <br />See attached <br />3 <br />. <br />0 <br />• <br />0 <br />• <br />0 <br />0 <br />■ <br />■ <br />■ <br />❑ <br />❑ <br />�, <br />SyLtt'D <br />4 <br />■ <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />■ <br />■ <br />■ <br />a <br />■ <br />= <br />5 <br />■ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />a <br />❑ <br />• <br />•, <br />6 <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />• <br />�. <br />7 <br />a <br />❑ <br />❑ <br />❑ <br />• <br />■ <br />■ <br />■ <br />❑ <br />❑ <br />. <br />❑ <br />. <br />■ <br />y <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />■ <br />❑ <br />❑ <br />ails 3 <br />cal <br />6 <br />9 <br />❑ <br />❑ <br />a <br />■ <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />❑ <br />Q <br />10 <br />■ <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />• <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:10/7/15 16:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by Date/Time: )1:0516,:b <br />Sample Disposal: Return to Client <br />■ Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />