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OZ 10 V l abed <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. 6319 4946 9792 <br />Project Name: Schwartz - IIIII <br />DATE: 11/24/15 SSTF: S28753 <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 />f e(:5 f -6f <br />5-Y/f <br />ELI Quote #: <br />L SO <br />9 <br />Report Required <br />Special Report <br />prior to sample <br />NELAC ■ <br />For: POTW/WWTP <br />Other <br />■ <br />Number of Containers <br />Sample Type: <br />AWSVBO <br />74/ 6ir, water Soils/Solids, Vegetation, <br />X Bioassay Other <br />ANALY f' 1'.i 'r_ 0ESTEG <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 />N 44/0 <br />Receipt temp <br />wl '-4 C <br />TABLE 2- <br />notified <br />V ■ <br />Cooler ID(s)c-, <br />ra- <br />Formats -- <br />submittal for <br />A2LA ■ <br />ELI must be <br />the following: <br />Level <br />Custody §tal <br />Y / 61 <br />Intact <br />YIN <br />Signature <br />Y/N <br />Match LAB ID <br />Y / N <br />Comments: <br />SSA Schedule Code : <br />GW CODE: <br />F uen c <br />Other <br />Format <br />Epp/EDT ■ <br />SAMPLE <br />IDENTIFICATION <br />(Name, Location, <br />Interval, etc) <br />Collection <br />Date <br />Collection <br />Time <br />Domestic Well <br />11/24/15 <br />11:15 <br />Water 3 <br />® <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />0 <br />_ <br />® <br />See attached <br />2 MW 0 <br />11/24/15 <br />13:20 <br />Water3 <br />IN <br />0 <br />0 <br />0 <br />❑ <br />0 <br />0 <br />0 <br />0 <br />® <br />0 <br />See Attached <br />(1S 11075C <br />US <br />1202) <br />• <br />3 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />° <br />❑ <br />❑ <br />❑ <br />0 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />5 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />CC <br />• <br />6 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />0 <br />7 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />ie <br />s <br />8 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑❑ <br />tr <br />9 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />© <br />❑ <br />❑ <br />❑ <br />- <br />- <br />10 <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />-T <br />❑ <br />❑ <br />Custody <br />Record <br />MUST be <br />Signed <br />Relinquished by: B•b Tennant Date/Time:11/24/1516:00 <br />Shipped by: FedExc,rg5-VI—Received <br />by Date/Time: tlh*✓Ni le.:0 <br />Received by: Date/Time: <br />Relinquished by: Date/Time: <br />Sh.pped by: <br />Sample Disposal: Return <br />Lab Disposal <br />® <br />LABORATORY USE ONLY <br />Sample Type # of fractions <br />to Client <br />■ <br />