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9i.;O g 96ed <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 7749 4791 9202 <br />Project Name: Schwartz <br />DATE:11/10/15, S28497 <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/WWTP <br />Other <br />■ <br />Number of Containers <br />Sample Type. <br />—i AWSVBO <br />Air, Water $drs/Solds. yeyetation. <br />X Aloassay Qther <br />ANALYSIS RIilUESTED <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />p additional charges <br />1- and scheduling <br />Receipt Temp <br />1.11L° C <br />Cooler ID(s) <br />U - dissolved only - CODE #1 <br />U - total & dissolved - CODE #3 <br />Ra -226 total & dissolved CODE#3 <br />— <br />/ <br />1 <br />Special <br />prior to sample <br />NELAC <br />Other <br />EDD/EDT <br />Report <br />elCustodya <br />■ <br />Formats <br />submittal <br />A2LA <br />Format <br />— ELI must be notified <br />for the following: <br />■ Level IV ❑ <br />l <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 />SW CODE I 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-ARH <br />11/10/15 <br />12:00 <br />Water 5 <br />0 <br />0 <br />0 <br />® <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />_ <br />0 <br />0 <br />See attached <br />> CISkt.03Qt f <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />''12.-1 <br />X <br />3 <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />❑ <br />4150 t.,,,,_ f h✓ <br />i <br />4 <br />❑ <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 />❑ <br />❑❑ <br />CC <br />6 <br />❑ <br />■ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Cl <br />❑� <br />Q <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />Ciie <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />O <br />CO <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />s <br />- <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:11/10/15 16 30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by. Date/Time: I 41/A5 16 <br />Sample Disposal: Return to Client <br />■ Lab Disposal <br />►.. <br />LABORATORY USE ONLY <br />Sample Type # of fractions �, <br />