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Enc-RG ' Chain of Custody and Anplytical Request Record <br /> `'"'`"= "`'("5 PLEASE PRINT: provide as much information as possible, Refer to corresponding notes on reverse side. Page 1 of 1 <br /> Company Name:Coiter Corporation Project Name: Schwa-Ili-110 <br /> Tracking No 7755 8887 0063 DATE:2/5/15,S28653,S28656 <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 /> 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 /> — <br /> ANAL'9 ' r.Cn Es1EO Notify ELI prior to �1 !rt <br /> RUSH sample <br /> Report Required For. POTWNWYrP 0 Receipt Temp <br /> Liu ,C <br /> Other Q <br /> P submittal for Cooler ID(s) <br /> Special Report Formats–EU must be notified i .. 2 a p additional charges <br /> prior to sample submittal for the following: l tm>1 i a 0 t t <br /> $ and scheduling <br /> >, 8 <br /> NELAC 0 A2LA 0 Level IV 0 g Custody Pieal <br /> Comments: Y l& <br /> Other U ' to3 <br /> EDD/EDT 0 Format `�'` S&A Schedule Code: intact <br /> z a a ies 12 SW CODE 11 Y/N <br /> SAMPLE x Table 1 Signature <br /> Y/N <br /> IDENTIFICATION Collection Collection 4Z11 n T `� Frequency 1, Match LAB ID <br /> (Name, Location, Date Time . T N Y 1N <br /> Interval,etc) MATRIX I _ <br /> 1 SW-AWD 2/5/15 9:15 Water 5 0 0 0 ® 0 0 0 0 0 0 ® See attached – <br /> sail <br /> 2 SW BPL 2/5/15 10:30 Water 5 0 0 0 ® 0 0 0 0 0 0 MISee attached ZA CHOZOZ 43 <br /> 3 0000000000 ❑ ❑ ILI <br /> 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 5 0 0 000000 0000 CC <br /> 6 0 , 0000000DODD <br /> 7 ❑ ❑ ' ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ D❑' <br /> ---►---- "CI <br /> 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ rx>! <br /> 9 00000000 DODD --x <br /> co <br /> co co <br /> 10 0 0 ❑ ❑ ❑ ❑ 0 0 0 0 ❑ ❑ <br /> Custody Relinquished by:Bob Tennant Date/Time:2/5/15 16:30 Shipped by: FedEx it f_y Received by: Date/Time: <br /> MUSTrd be Relinquished by: Date/Time: Shipped by: Received by' -Date/Time:z`" <br /> Signed Sample Disposal: Return to Client 0 Lab Disposal LABORATORY USE ONLY <br /> ® <br /> Sample Type #of fractions_ <br />