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v <br />CD0 <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. 7749 2237 2177 <br />Project Name: Schwartz -' <br />DATE: 11/6/15 SSTF: S28448 <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 />NELAC 0 <br />Other <br />EDD/EDT 0 <br />For: POTWMIVVrP <br />Other <br />■ <br />g Number of Containers <br />> Sample Type: <br />—I AWSVBO <br />PZI Air, Water$oils/Solids, Vegetation, <br />X Qioassay Qther <br />ANALYST' -,E:(uESTED <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 jfi <br />TABLE 2 - <br />TOC Total Carbon <br />i3 <br />m <br />p <br />Ra 228 + 228 Total <br />As Ba Fe Mn Mo U Total <br />TABLE 4 <br />notified <br />IV ■ <br />Formats — ELI must be <br />submittal for the following: <br />A2LA 0 Level <br />Format <br />Cooler ID(s) , <br />G„, IC <br />Custody al <br />Y /61 <br />Intact L <br />Y / N <br />Signature <br />Match LAB ID <br />YIN Y / N <br />Comments: <br />SM Schedule Code : <br />GW CODE: <br />Fre uen <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc)_ <br />Collection <br />Date <br />Collection <br />Time <br />Mine Refill <br />11/6/15 <br />8:30 <br />Water 1 <br />0 <br />0 <br />0 <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />See attached <br />I>,--- <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />a(tSllot9i <br />00000E1 <br />0•00 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />.0 <br />= <br />❑ <br />❑ <br />❑ <br />❑ <br />_:PP"' <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />■ <br />e <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />le— <br />le— <br />.. <br />' <br />000000. <br />e <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑' <br />WA <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <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:11/6/15 16 30 <br />Sh <br />pped by: <br />FedEx (t5.4/ <br />Received by: Date/Time: tt Nil y i' <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: Date/Time: <br />Sample Disposal: Return <br />Lab Disposal <br />- LABORATORY USE ONLY <br />Sam. le T •e # of fractions <br />to Client ■ <br />