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E/\ERGY Chain of Custody and Analytical Request Record <br /> PLEASE PRINT;provide as much information ascorresponding Page possible. Refer to comes ondin notes on reverse side. Pa e 1 of 1 <br /> Company Name: Cotter Corporation Project Name: SchwarliAlli <br /> Tracking No. 7758 0274 0450 DATE: 3/4/16 SSTF: S287O5, S28707 <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 /> Al ALYSI= :,3 4.:a'EL Notify ELI prior to <br /> Report Required For POTWMIW TP❑ - RUSH sample Re4 int 1R�n C • <br /> Other submittal for l�ID(s) <br /> Special Report Formats-ELI must be notified < p additional charges c <br /> � <br /> prior to sample submittal for the following: . o'4 t and scheduling Custody Seal <br /> NELAC❑ A2LA❑ Level IV❑ $ i a g Comments: Y 1� <br /> EDD EDT 0 Format ` ,A F er os E &A SSchedule Code: Intact <br /> W _ CODE: Y l N <br /> SAMPLE N € x Signature <br /> YIN <br /> IDENTIFICATION Collection Collection RI w Z Fr Match LAB ID <br /> (Name,Location, Date Time < Y/N <br /> Interval,etc) MATRIX F- <br /> ' MW f 0 3/4/16 10:00 Water 3 0 ❑ 0 0 ❑ 0 ❑ ❑ ❑ ❑ 0 ❑ See attached <br /> 2 MW 1 314/16 12:50 Water 3 0 0 0 0 0 0 0 0 0 0 ® ❑ See attachedC[�p3022- <br /> 9 ❑ ❑ ❑ ❑ ❑ _ ❑ ❑ ❑ ❑ ❑ <br /> ____ <br /> I 0 <br /> 4 ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑ ❑ ❑ ❑ „'7t <br /> s ❑ ❑ ❑ ❑ r ❑ ❑ ❑ ❑ ❑ ❑ o ❑ ; <br /> 000000000000 <br /> ' ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑� ❑ ❑ ❑ ❑ '---- <br /> Cr <br /> B ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ O o <br /> 9 ❑ ❑ ❑ a ❑ ❑ ❑ ❑ ❑ ❑cc _ o <br /> 0 10 ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> w <br /> ° Custody Relinquished by: Bob Tennant Date/Time:3/4/1616:00 Shi••_• b : FedEx a.•me' - Received b : Date/Time: <br /> °' Record Relinquished by: Date/Time: Shipped by: A T �� Received by.;•►# Date/Time: s <br /> MUST be LABORATORY USE ONLY <br /> Signed Sarrpple Disposal: Return to Client 0 Lab Disposal® Sample Type #of fractions„ , <br />