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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 />a1 <br />Company Name: Cotter Corporation <br />Tracking No. 7750 0512 8450 <br />Project Name: Schwartz <br />DATE: 11/17/15 SSTF: 528524 <br />- <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 <br />Special Report <br />prior to sample <br />For. POTWMIWTP <br />Other <br />notified <br />II <br />Number of Containers <br />Sample type: <br />AWSVBO <br />13 Air, Water Yepetatlon, <br />X gioaesay Qther <br />ANALYs: s ctroussreo <br />Notify ELI prior to <br />RUSH sample <br />submittal for <br />i= additional charges <br />t and scheduling <br />Receipt Temp <br />1. t.P ° C <br />Cooler IDs) <br />Formats — ELI must be <br />submittal for the following: <br />NELAC 0 <br />Other <br />EDD/EDT 0 <br />A2LA ■ <br />Level IV 0 <br />N <br />Normal Tumarourw <br />RUSH Turnaround <br />Comments: <br />SSA Schedule Code :Intact <br />GW CODE: <br />Ue" <br />od I <br />CustY y <br />Y / N <br />Signature <br />Y / N <br />Match LAB ID <br />Y / N <br />Format <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />1 MW 00 <br />11/17/15 <br />11:00 <br />Water 3 <br />® <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 0 0 See attached <br />2 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑❑ <br />❑ <br />❑ <br />❑❑ RS -1A <br />-177 <br />Z <br />MA <br />= <br />3 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 0 45C$ <br />❑ ❑ tV <br />9 <br />• <br />4 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />S <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />ed <br />6 <br />❑ <br />❑ <br />❑_ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />• <br />7 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 0 0 C/SI)b pGZ <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ ❑ ❑ <br />10 <br />❑ <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 ❑ ❑ <br />. <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: f3ob Tennant Date/Time:11/18/1516:00 <br />Shipped by: FedEx Received by:' Date/Time: <br />t11fh15 }t,_ <br />Relinquished by: Date/Time: <br />Shipped by: Received by: Date/Time: <br />Sample Disposal: <br />Return <br />Lab <br />Disposal <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />to Client <br />■ <br />.d <br />