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Co <br />th <br />CD0 <br />J <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 />Tracking No. 7746 4471 2742 <br />Project Name: Schwartz - <br />DATE: 10/1/15 SSTF: S28437 <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 />Number of Containers <br />Sample Type: <br />-� AWSVBO <br />X jposesay Oberb"' Y tion. <br />ANALYSIS 4?EQUESTED <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />for <br />Tempt Receipt <br />2p <br />4 <br />submittal <br />Report Required For. POTWNVWTP 0 <br />Other <br />TABLE 2 - <br />TOC Total Carbon <br />As Ba Fe Mn Mo U Total <br />F additional charges <br />t and scheduling <br />CA jerr ID� <br />Special Report Formats — ELI must be notified <br />prior to sample submittal for the following: <br />NELAC 0 A2LA 0 Level IV 0 <br />Other <br />EDD/EDT 0 Format <br />1 <br />_ <br />$ <br />ce <br />Comments: <br />S&A Schedule Code : <br />GW CODE: <br />Fuen <br />Custod al <br />YO) <br />Intact <br />Y / N <br />Signature <br />Match LAB ID <br />Y / N <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />'' <br />co <br />M <br />m <br />+- <br />1 Mine Refill <br />10/1/15 <br />10:00 <br />Water 1 <br />0 <br />El <br />❑ <br />• <br />• <br />El <br />❑ <br />❑ <br />• <br />0 <br />® <br />• <br />See attached <br />)1,- <br />2 <br />❑ <br />• <br />. <br />. <br />. <br />. <br />❑ <br />. <br />. <br />❑ <br />CIO <br />0 <br />❑ <br />■ <br />■ <br />■ <br />❑ <br />■ <br />• <br />❑ <br />❑ <br />■ <br />❑ <br />• <br />C�L��S <br />s� <br />W <br />yo <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 />O <br />0 <br />CC <br />e <br />■ <br />■ <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />■ <br />❑ <br />■ <br />0 <br />❑ <br />—4 <br />— <br />ce <br />co _ <br />co <br />sr <br />7 <br />• <br />❑ <br />❑ <br />• <br />❑ <br />❑ <br />. <br />❑ <br />❑ <br />■ <br />-. <br />II; <br />6 <br />a <br />■ <br />■ <br />a <br />. <br />O <br />❑ <br />❑ <br />❑ <br />• <br />c <br />❑ <br />9 <br />. <br />❑ <br />• <br />❑ <br />• <br />❑ <br />❑ <br />• <br />• <br />❑ <br />0 <br />■■ <br />.. a _ <br />10 <br />❑ <br />❑ <br />• <br />C10000•0 <br />❑ <br />• <br />Custody <br />Relinquished by:Bob TennantDate/Time:10/1/1516 30 <br />Sh <br />pped by: <br />FedEx <br />Received by: Date/Time: <br />Record <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: ('Date/Time: 10 7415 K: 01 <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ■ <br />Lab Disposal <br />►�l <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />