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 58831539 DATE: 7/27116 SSTF:S29116
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. 204 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] 0, 1cc
ANALYS REQUESTED Notify ELI prior to Receipt mp
Report Required For: POTWNVWTP❑ RUSH Receipt
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Other a submittal for
Special Report Formats—ELI must be notified .. S Q q additional charges Cooler ID(s)
prior to sample submittal for the following: �m" a t and scheduling
NrC❑ A2LA[I Level IV Elf� o Q Comments: CustodyYY//69 l
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a , °0 S&A Schedule Code: Intact
EDD/EDT❑ Format i r a GW CODE: Y/N
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IDENTIFICATION Collection Colection a'� Y/N
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Interval,etc) MATRIX
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CD w Custody Relinquished by: Bob Tennant Date/Time:7/27/16 b : FedEx— S• Received by: Date/Time:
° Record Relinquished by: Date/Time: by: Received by."gr Date/Time:
MUST be LABORATORY USE ONLY
Signed Sample Disposal: Return to Client 0 Lab Disposal® Sample T #of fractions