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cn'IGY Chain of Custody and Analytical Request Record <br /> , ```"''' "`'t' PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1 <br /> Company Name:Cotter Corporation Project Name: Schwartz-MI <br /> Tracking No.7758 9211 7877 DATE:3/16/16 SSTF: S28711, $28718 , S28720 <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 /> ANALYSIS R`:T;UESThD Notify ELI prior to R-1 <br /> Report Required For: POTWNWVTP 0 I RUSH sample Receipt Tefnp <br /> Other . submittal for Z.6 °C <br /> Special Report Formats-ELI must be notified c t additional charges Cooler ID(s),';11 <br /> prior to sample submittal for the following: > 2 t and scheduling Custody Seal <br /> NELAC❑ A2LA❑ Level IV❑ �, I g Comments: ,�c� <br /> Other $ 3 Y/r7 <br /> EDD/EDT❑ Format < E SMA Schedule Code: Intact <br /> z ~ GW CODE: Y/N <br /> SAMPLE 1 T Signature <br /> i n ' z a Y/N <br /> IDENTIFICATION Collection Celled o F <br /> (Name,Location, Date lime ; Match LAB ID <br /> Interval,etc) MATRIX '- Y/N <br /> 1 MVV 15 3/15/16 13:00 Water 3 123000000000 =1 See attached )0-. <br /> mail -- <br /> 2 MW 13 3/16/16 11:00 Water 3 ® 0 0 0 0 0 0 0 0 0 0 0 See attached ZZ <br /> 3 MW 14 3/16/16 12:45 Water ® ❑ 0 0 0 0 0 0 0 0 ® See attached <br /> 0 0 0 0 0 0 0 0 0 0 ❑ ❑ CL1,Q0305b5 _ <br /> 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ _" <br /> 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0 CO <br /> 0 0 0 0 0 0 0 0 0 0 0 0 >oG <br /> COI <br /> 9 ❑ ❑ ❑ ❑ ❑ CI ❑ ❑ ❑ ❑ El .mss <br /> 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ` <br /> Custody Relinquished by:Bob Tennant Date/Time:3/16/1616:00 Shipped by: FedEx -C- t7 Al Received by: Date/Time: <br /> o Record Relinquished by: Date/Time: Shipped by: Received by: Date/Time: }7 <br /> MUST be :0 • * - ONLY <br /> `° Signed Sample ■ . . .. _ ►8 -• <br />