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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 3383 4934 DATE:6/02/15 SSTF: S28964,S28968 <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 ��t <br /> RUSH <br /> ELI prier to R�mp <br /> Report Required For: POTWNVWfP❑ � � RUSH sample a C <br /> Other * submittal for Cooler 10s) <br /> Special Report Formats—ELI must be notified $o� ;� w o a additional charges <br /> prior to sample submittal for the following: 5�,m W $ g t and schedulin l <br /> NELAC❑ A2LA❑ Level IV❑ $ N $ o g Comments: Custody <br /> Other <br /> 3 <br /> c� o Y/V <br /> EDDlEDT❑Format �'a r E S&A Schedule Code: Intact <br /> i ® r 0 ~ ' SW CODE I1 Y/N <br /> c i Table 1 Signature <br /> SAMPLE 0 <br /> IDENTIFICATION Collection Collection « c N o Frequency 1, Y J N <br /> Match LAB ID <br /> (Name, Location, Date Time <br /> Interval, etc) MATRIX '' Y/N <br /> ' SW-BPL 6/02/16 9:45 Water 5 ❑ ❑ ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ See attached <br /> TI <br /> 2 SW LLHG 6/02/16 15:00 Water 5 ❑ El ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ See attached Z <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> a ❑ 1-] ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ c t <br /> 5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1010 ❑ ❑ <br /> 6 ❑ ❑ 1 ❑ D ❑ ❑ ❑ ❑ ❑ ❑ O D , <br /> 7 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ D D ❑ : <br /> 8 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 9 ❑ ❑ ❑ ❑ ❑ D ❑ ❑ ❑ ❑ ❑ ❑ <br /> 10 ❑ ❑ ❑ ❑ ❑ ❑ F0 ❑ ❑ ❑ ❑ ❑ <br /> Custody Relinquished by: Bob Tennant Date/Time:6/02/15 16:30 Shipped by: FedEx Received by: Date/Time: 3 <br />' Record Relinquished by: Date/Time: Shipped by: Received by: Date/Time: <br /> MUST be LABORATORY USE ONLY <br />' Signed Sample Disposal: Return to Client❑ Lab Disposal® Sam le T #of fractions <br />