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v <br />CD <br />CD <br />01 <br />0 <br />co <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. 7750 0512 8450 <br />Project Name: Schwartz -' <br />DATE: 11/17/15 SSTF: a28522 <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 />ID Sample <br />ll qtr, Water $oilslSolids, Vegetation, <br />X Bioassay gther <br />ANALYSI . REQUESTED <br />Normal Turnaround (TAT) <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />p additional charges <br />t and scheduling <br />Receipt Temp <br />I'L° ° C <br />TABLE 2 - <br />TOC Total Carbon <br />TDS SO4 Ci Total <br />Ra 226 + 228 Total <br />As Ba Fe Mn Mo U Total <br />ill <br />1- <br />Cooler IDI <br />cLA <br />Special <br />prior to sample <br />NELAC <br />Other <br />EDD/EDT <br />Report <br />MIA2LA <br />■ <br />Formats <br />submittal <br />Format <br />- ELI must be notified <br />for the following: <br />II Level IV 0 <br />Custody�Stral <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 />SBA Schedule Code : <br />GW CODE: <br />Fre <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />1 Mine Refill <br />11/17/15 <br />11:00 <br />Water 1 <br />0 <br />o- <br />0 <br />0 <br />0 <br />® <br />0 <br />0 <br />0 <br />0 <br />la <br />0 See attached <br />)0- <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑❑, <br />0 <br />LU <br />Vit <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />4 <br />' <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />= <br />5 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />• <br />0 <br />0 <br />0 <br />0 <br />0 0.15 I I B ivla I <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />• <br />ACE <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />d <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />m <br />.vi: <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />-..4 <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:11/18/15 16:30 <br />Shipped by: FedEx <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Sh'pped by: <br />Received by:1P Date/Time: 446 Ltt <br />Sample Disposal: Return to Client ■ <br />Lab Disposal ® <br />LABORATORY USE ONLY <br />Sam.le T •e # of fractions <br />