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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. 7749 5618 4129 <br />Project Name: Schwartz - <br />DATE: 11/11/15 SSTF: 528498,528500 <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 />— <br />Report Required <br />Special Report <br />prior to sample <br />NELAC ■ <br />For. PO7V1►NVWTP <br />Other <br />❑ <br />notified <br />IV ■ <br />Number of Containers <br />Sample Type. <br />AWSVBO <br />Air, Water antis/Wide, Vegetation, <br />X ¢ioassay giber <br />ANALY$. _. :OUESTEI. <br />Normal Turnaround (TAT) <br />RUSH Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />additional charges <br />and scheduling <br />Receipt Temp <br />° C <br />TABLE 2- <br />Cooler D(s) <br />Formats - <br />submittal for <br />A2LA IILevel <br />ELI must be <br />the following: <br />Custody <br />Y 1 <br />Intact <br />Y / <br />Y/N <br />Match I <br />Y <br />A� <br />eal <br />ID <br />Comments: <br />SMA Schedule Code : <br />GW CODE: <br />Fru <br />Other <br />Format <br />EDD/EDT ■ <br />SAMPLESignature <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />SUMP 10 <br />11/11/15 <br />11:00 <br />Water 3 <br />CO <br />❑ <br />D <br />D <br />D <br />❑ <br />0 <br />0 <br />0 <br />0 ® <br />0 <br />See attached <br />>- CSO <br />z SUMP 5 <br />11/11/15 <br />13:00 <br />Water 3 <br />® <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 El D <br />See Attached <br />= <br />0000000 <br />0 <br />0 <br />0 0 0 <br />Cd,l Et51t01{tZ <br />❑ <br />D <br />D <br />❑ <br />❑ <br />❑ <br />❑ <br />D <br />❑ <br />❑ ❑ 0 <br />5 <br />0 <br />❑ <br />0 <br />❑ <br />0 <br />D <br />0 <br />❑ <br />0 <br />D <br />0 <br />❑ <br />0 <br />❑ <br />0 <br />❑ <br />0 <br />D <br />, <br />0 0 0 <br />❑ D ❑ <br />.Il= <br />LI <br />B <br />00000E1 <br />000000 <br />cc: <br />e <br />000d <br />D ❑ <br />e <br />•000000■ <br />D <br />B <br />D❑❑❑ <br />D <br />D❑❑❑ <br />10 <br />Sh'pped <br />by: <br />FedEx <br />5-A' <br />Received <br />Received <br />by::- ,'. Date/Time: <br />by: Date/Time: <br />Wit/15 10, <br />000000000000 <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: Bob Tennant Date/Time:11/11/1516:00 <br />Relinquished by: Date/Time: <br />Shipped by: <br />Sample Disposal: Return to Client ❑ Lab Disposal <br />LABORATORY USE ONLY <br />Sample Type # of fractions _, <br />r <br />