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Aaw Chain of Custody and Analytical Request Record <br /> 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 - <br /> Tracking No 7764 2044 6054 DATE:6/01/15, S28956 <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 /> rap;AL'v Notify ELI prior to Receipt Temp <br /> Report Required For: POTWANUYfP❑ RUSH sample <br /> �`o C <br /> Other F submittal for <br /> Special Report Formats—ELI must be notified .. < F additional charges Cooler ID(s) <br /> prior to sample submittal for the following: $°m'r w t and schedulingWL' <br /> NELAC❑ A2LA❑ Level IV❑ ' o o o g Comments: <br /> Custod I <br /> d�, o y <br /> 3 jz <br /> Other " Co w Y <br /> E D/EDT[I Format aS&A Schedule Code: intact <br /> z t �e SW CODE 11 Y/N <br /> SAMPLE a e Z x Table 1 Signature <br /> IDENTIFICATION Collection Collection ��� z D Frequencyl 1, Y/N <br /> (Name, Location, Date Time N Match LAB ID <br /> Y/N <br /> Interval, etc MATRIX <br /> > > <br /> ' SW-AWD 6/01/15 12:00 Water 5 ❑ ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ® 1 ❑ See attached . <br /> 2 1 ❑ ❑ ❑ ❑ ❑ ❑ 10 ❑ ❑ ❑ ❑ ❑ <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ t O� <br /> 4 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0101 <br /> 6 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ rM <br /> 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Ce <br /> a ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 01 01 .,L, <br /> 9 ❑ 10 1 ❑ ❑ 1 ❑ 10 10 10 101 ❑ ❑ ❑ <br /> 10 ❑ ❑ ❑ ❑ 1 ❑ 1 ❑ I ❑ 10 101 ❑ ❑ ❑ <br /> Custody Relinquished by:Bob Tennant Datelrime:6/01/15 16:30 Shipped by: FedEx Received by: Date/Time: <br />' Record Relinquished by: Date/Time: Shipped by: Received by: Date/Time:1-h4l <br /> MUST be LABORATORY USE ONLY <br /> Signed Sample Disposal: Return to Client El Lab Disposal® Sample Type #of fractions <br />