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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: Schwarbe- <br /> Tracking No.7769 6727 6190 DATE:8/10/16 SSTF: S29185 <br /> Report Mail Address: — <br /> Cotter Corporation-Canon C' Mill Sampler Name if other than Contact: <br /> PO Box 1750;Canon City, CO 81215-1750 � Name: N 719-27-7413 ext. 208 1-303-642-3893 mine phone <br /> tnvo;cr Aaarm: Bob Tennant 1-719-371-3009-cell <br /> PO Box 1750 Invoice Contact: Lori Simpson Purchase Order#: ELI Quote#: <br /> Canon City,CO 81215-1750 Tel: 1-719-275-7413 ext. 207 <br /> Fax: 1-719-275-1669 <br /> Re ANAL YStS RLOVEti3 f. Notify ELI prior to -� <br /> Report Required For: POTWNVWTP❑ RUSH sample R ip Temp <br /> Other submittal for <br /> C <br /> Special Report Formats—ELI must be notified Cooler ID(s) iLG <br /> Prior to sample submittal for the following: a additional charges <br /> a� <br /> NELAC❑ A21,A > V t and scheduling <br /> ❑ level IV❑ a 3 0 g Comments: Cus Seal <br /> Other Y N <br /> EDD/EDT❑Format < _ 2 <br /> E In <br /> z � � o o � `� S8�A Schedule Code <br /> �- 9 GW CODE: it N <br /> SAMPLE U = Sign re <br /> IDENTIFICATION Collection Collection s w z DF1 N <br /> (Name, Location, Date Time a3 F Mat LAB ID <br /> Interval, etc MATRIX a /N <br /> � Mine Re z 8/10/16 15:30 Water 3 <br /> ❑ ❑ ❑ ❑ ❑ ® ❑ ❑ ❑ ❑ ® ❑ See attadmd >- <br /> w <br /> ary <br /> 5 ❑ ❑ ❑ 1 ❑ 10 1 ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ <br /> ❑ D ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ O ❑ O ❑ ❑ ❑ D ❑ ❑ ❑ ❑ <br /> e <br /> a ❑ a ❑ ❑ ❑ ❑ ❑ ❑ D ❑ ❑ <br /> s <br /> ❑ ❑ ❑ ❑ a ❑ ❑ ❑ ❑ D ❑ ❑ r <br /> ❑ ❑ ❑ ❑ ❑ ❑ 01 ❑ D ❑ ❑ ❑ .G <br /> io <br /> a D a ❑ D ❑ ❑ ❑ 1P ❑ ❑ ❑ <br /> Custody Reli quished bv:Bob Tennant Date/Time:8/10/16 16:30 Shi b : FedEx&dpA Received by: Date/Time: <br /> Record Relinquished by: Date/Time: Shipped by: Received by: Datemme: <br /> MUST be <br /> Signed Sample Disposal: Retum to Client❑ Lab DisposalLABORATORY USE ONLY <br /> ® Sample Type #of fraction . <br /> 4 '09"b <br />