2016-09-13_HYDROLOGY - M1977300

• Permit No: M1977300
• IBM Index Class Name: HYDROLOGY
• Doc Date: 9/13/2016
• Media Type: D
• Archive: No

Chain of Custody and Analytical Request Record
PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1
Company Name: Cotter Corporation Project Name: Schwartz -
Tracking No. 7768 7971 3498 DATE: 7129/16 SSTF:S291 1 8
Report Mail Address: Sampler Name if other than Contact:
Cotter Corporation-Canon City Mill Contact Name: Nate Lambert 1-303-642-3893 mine phone
PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 208 Bob Tennant 1-719-371-3009-cell
Invoice Address: Invoice Contact: Lori Simpson Purchase Order* ELI Quote#:
PO Box 1750 Tel: [phone] ext. 207
Canon City, CO 81215-1750 Fax: [phone]
Notify ELI prior to
Report Required For: POTWNVWTP El RUSH sample Receipt amp
Other r submittal for let' C
Special Report Formats—ELI must be notified I ..o F additional charges Cooler�D f b
-�,prior to sample submittal for the following: Em ,; and schedulin �'P
NELAC❑ A2LA❑ Level IV❑ a o Comments: Custody Seal
Y/®
Other 2 1 m 2EDD/EDT❑ Format E`�<A a E SBA Schedule Code: Intact
= b GW CODE: Y/N
SAMPLEI N Signature
IDENTIFICATION Collection Collection ' z D Y/N
Fre Match LAB ID
(Name, Location, Date Time a
Y/N
Interval, etc) MATRIX
' MW 19 7128/16 12:45 Water 3 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ See attached
2 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 10 FO ❑
3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
5 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0101
};
10 01010 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑
Custody Relinquished by: BobTennant Daterrime:7/29/1616:00 I Shipped by: FedEx Received by: Date/Time:
Record Relinquished by: Date/Time: Shipped by: Received by: Date/Time: (U.
MUST be LABORATORY USE ONLY
Signed Sample Disposal: Return to Client❑ Lab Disposal ® Sample Type #of fractions