Laserfiche WebLink
EI\RGY Chain of Custody and Analytical Request Record <br /> PLEASE PRINT; provide as much information <br /> as possible. Refer to corresponding notes on reverse side. Page 1 of 1 <br /> Company Name: Cotter Corporation Project Name: Schwartz - <br /> Tracking No.7753 6868 6118 DATE: 1/7/16 SSTF: S28557,628560 <br /> - <br /> Report Mail Address: Sampler Name if other than Contact: <br /> Cotter Corporation-Canon City Mill Contact Name: Frank Adamic 1-303-642-3893 mine phone <br /> PO Box 1750;Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 204 Bob Tennant 1-719-371-3009-cell <br /> _ <br /> Invoice Address: Invoice Contact: JoAnne Ary Purchase Order#: ELI Quote#: <br /> PO Box 1750 Tel: 1-719-275-7413 ext. 209 <br /> Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> ANALYSIS REQUESTED Notify ELI prior to Ri t Temp <br /> Report Required For: POTW/ Wece <br /> TP❑ RUSH sample pt C <br /> Other . submittal for <br /> Special Report Formats—ELI must be notified I .o i t a additional chargesCooler ID(s) <br /> ) <br /> prior to sample submittal for the following: A Pm' , t and scheduling y <br /> NELAC 0 A2LA 0 Level IV 0 ` <br /> g Comments: Cush:A I <br /> Other a 3 i a g Y! <br /> EDD/EDT❑ Format 1 <br /> A SBA Schedule Code Intact <br /> z ffi rce F GW CODE: Y/N <br /> SAMPLE A N U R i 3 5 Signature <br /> IDENTIFICATION Collection Collection 't i t p- + " la z F u Y/N <br /> m N N 12 d Match LAB ID <br /> (Name, Location, Date Time F �' Y/N <br /> Interval, etc) MATRIX _ <br /> , Mine Refill 1/7/16 9:45 Water 1 0 0 0 0 0 ® 0 0 0 0 ® ❑ See attached ›►- <br /> 2 MW 20 1f7/16 13:45 Water 3 IR 13 1:113 ❑ 130000 ® 1:1 See attached 0 <br /> " ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Gtlo011ta? <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ft , .h(Q <br /> 5 ❑ 0 0 0 0 0 0 0 0 0 0 0 ✓rc4r�td �0 <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ T.wttn c,,4 <br /> ' 0 0 0 ❑ ❑ 0 0 0 0 0 0 0 ii.-6.1(411, cc <br /> 0 <br /> 8 _ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ itIO 1424 Uo,ce'Its I <br /> 9 0000000000 ❑ ❑ 1'. 3 1. 11-J(p .r <br /> 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> co <br /> Custody Relinquished by:Bob Tennant Date/Time:1/7/1616:30 ' Shipped by: FedEx f5.V Received by: DatefTiime: <br /> Record Relinquished by: Date/Time: Shipped by: Received byVas,..Date/Time: vitil‘ <br /> MUST be - it.l'i <br /> LABORATORY USE ONLY <br /> Signed Sample Disposa ®l: Return to Client 0 Lab Disposal <br /> 9 Sample Type #of fractions <br />