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EnERcy Chain of Custody and Analytical Request Record <br /> PLEASE PRINT; provide as much information as corresponding notes on reverse side. Page 1 of 1 <br /> possible. Refer to <br /> Company Name:Cotter Corporation Project Name: Schwarti <br /> Tracking No. 7757 9204 2666 DATE: 3/3/16 SSTF: S2$700,$28702 <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 /> ANALYSIS i. ' .s :iT'c .D Notify ELI prior to 1 i<ice <br /> Report Required For: POTW/WWTP 0 I RUSH sample Rec#Ipz Temp <br /> Other submittal for �� D( <br /> Special Report Formats-ELI must be notified I ..o� t a additional charges Cooler 1 s) <br /> prior to sample submittal for the following: m • a and scheduling <br /> NELAC❑ A2LA❑ Level IV❑ ~' $ Custody Seal <br /> >s y g Comments: Y/ <br /> Other a• o H I S&A Schedule Code: Intact <br /> EDD/EDT❑Format = $r o -. GW CODE: Y/N <br /> SAMPLE 0 2 io r Signature <br /> IDENTIFICATION Collection Collection ii• 14 P. g + e W z a Y/N <br /> m F Match LAB ID <br /> (Name, Location, Date Time i �, d, Y/N <br /> Interval,etc) MATRIX '- ' re a '- —,r Mine Refill 3/3116 9:00 Water 1 ID CO ❑ ❑ ❑ ® ❑ ❑ ❑ ❑ 1 D ❑ See attached .),t <br /> 2 moo <br /> 3/3116 12:15 Water 3 ® 00000000 0 ® 0 See attached = <br /> 5 ❑ ❑ ❑ ❑ ❑ ❑_ ❑ ❑ ❑ ❑ 0 ❑ w <br /> 0 0 0 ° ° D °❑ ❑ ❑ 0 0 0 C16D3DIE5 <br /> 5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Ce <br /> 0 0 0 0 0 0 0 0 0 06 ❑ ❑❑ <br /> 7 ❑ ❑ ❑ ❑ ❑ - ❑ ❑ ❑ ❑ ❑ ❑ ❑ c• 3 <br /> 8 0 0 0 0 0 0 0 0- - . <br /> 0 0 p . ❑ CO <br /> 9 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ - <br /> co ,o ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Custody Relinquished by:Bob Tennant Date/Time:3/3/16 16:30 , Shipped by: FedEx 12,-/V Received b : Date/Time: <br /> o Record Relinquished by: Date/Time: Shipped by: Received by: Date/Time: 6; 1 <br /> MUST be LABO ORY USE ONLY <br /> Signed Sample Disposal: Return to Client 0 Lab Disposal 0 Sample Type #of fractions,� <br />