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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] <br /> Company Name:Cotter corporation Project Name: Schwartz- <br /> Tracking No. 7770 2849 6240 DATE:8/18/16 SSTF:S29144,S29146 <br /> Report Mail Address: Sampler Name if other than Contact: <br /> Cotter Corporation-Canon City Mill Contact Name: Nate Lambert 1-303-642-3893 mine phone <br /> PO Box 1750;Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 208 Bob Tennant 1-719-371-3009-cell <br /> Invoice Address: Invoice Contact: Lori Simpson Purchase Order#: ELI Quote#: <br /> PO Box 1750 Tel: 1-719-275-7413 ext. 207 <br /> Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> 'I$REQ+.a Notify ELI prior to <br /> Report Required For: POTW/WWTP❑ RUSH sample Receipt Temp <br /> IS.Other r submittal for C <br /> Special Report Formats—ELI must be notified � .. 1 a F additional charges A-ler Akk <br /> prior to sample submittal for the following: tm" t and scheduli <br /> Smal <br /> NELAC❑ A2LA[I Level IV El ~y Q g Comments: CustodYU <br /> Other co <br /> EODIEDT❑Format a t F E S&A Schedule Code: Intact <br /> z o GW CODE: Y/N <br /> SAMPLE N co Signature <br /> IDENTIFICATION Collection Collection Z Ir F Math LAB ID <br /> (Name,Location, Date Time Y/N <br /> Interval,etc) MATRIX ~ <br /> MW 00 8/18/16 10:15 Water 3 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 0101 See attached <br /> s SUMP1 8/18/16 13:30 Water 3 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ® ❑ See attached ;z <br /> 3 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 5 ❑ ❑ ❑ ❑ 010 , 0 ❑ ❑ ❑ ❑ 01 � <br /> 10 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ © ❑ <br /> Custody RelinquishedBob T nn n Date/Time:8/18/1616:00 Shipped by: FedEx Received by: Date/Time: <br /> Record Relinquished by: DatetTime: Shipped by: Received by: Q Dat&7ime:a 1q Ito ItSS <br /> MUST be LABORATORY USE ONLY <br /> Signed Sample Disposal: Return to Client❑ Lab Disposal® Sample Type #of fractions <br />