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coN <br />W <br />0 <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 7744 2840 1701 <br />Project Name: Schwartz - IIIII <br />DATE:9/02/15 SSTF:S28357, S28359ThS28361 <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/WVIirP <br />Other <br />■ <br />gNumber of Containers <br />> Sample Type. <br />^i AWSVBO <br />Air, Waters/Solids, Vegetation, <br />X Bioassay Qther <br />4:r:<.. :, i:1 -;.r_:-, -r, <br />Normal Tumaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal forc <br />p additional charges <br />. and scheduling <br />Re .pemp <br />o C <br />U - dissolved only - CODE *1 <br />U - total & dissolved - CODE #3 <br />Ra -226 total & dissolved CODE#3 <br />s <br />1- <br />e , , <br />,°�� l,�s) <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 al <br />Y <br />Intact <br />Y/N <br />Signature <br />Y / N <br />Match LAB ID <br />Y / N <br />RUSH Turnaround <br />Comments: <br />S&A Schedule Code : <br />SWCODEI1 <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 />9/2/15 <br />11:15 <br />Water 6 <br />® <br />0 <br />0 <br />® <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />ID <br />0 <br />I See attached <br />2 SW-BOS <br />9/2/15 <br />12:15 <br />Water 1 <br />® <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />® <br />0 <br />See attached <br />4 <br />3 SW -GS <br />9/2/15 <br />12:30 <br />Water 1 <br />ID <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />0 <br />® <br />0 <br />See attached <br />4 SW -BPL <br />9/2/15 <br />13:00 <br />Water 6 <br />® <br />0 <br />0 <br />® <br />0 <br />■ <br />0 <br />0 <br />0 <br />0 <br />® <br />See attached <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />D <br />›„ <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />7 <br />0 <br />0 <br />0 <br />00000 <br />0000 <br />' <br />8 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />❑ <br />.w, <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />❑ <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:9/2/15 16:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received byi Date/Time: 9 j39IS ((•35 <br />Sample Disposal: Retum to Client 0 Lab Disposal ® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />