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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 2 Of 2 <br /> Company Name: Cotter Corporation Project Name: Schwartzwaider <br /> Tracking No. 3692013 00179520 Water Monitoring Program <br /> REF #/ DATE: 8/17/2010 <br /> Report Mail Address: Contact Name: Kristy Usnick Sampler Name if other than Contact: <br /> Canon City, Mill 1-719-275-7413 EX 213 Bob Tennant <br /> PO Box 1750 81215-1750 <br /> Invoice Address: Invoice Contact & Phone #: Purchase Order ELI Quote #: <br /> Canon City Mill Kristy Usnick 2563 <br /> PO. Box 1750 81215-1750 1-719-275-7413 EX 213 <br /> Report Required For: POTWNWVfP ? DW ? Notify ELI prior to RUSH sample <br /> Oth iF <br />T <br /> er e d F submittal for additional charges and <br /> Special Report Formats - ELI must be noted <br />rior to = h <br /> p .. o ; e edulin <br />a sc <br />l <br /> sample submittal for the following: <br />NELAC El A2LA ? Level IV ? a m `? <br />m W t Comments: oo <br />er <br />r <br /> en limited <br /> Other Jr. E extend C <br />ustoc <br /> EDD/EDT Format VC W l-' see alt. Table 3 Intact <br /> <br />SAMPLE IDENTIFICATION <br />Collection <br />Collection _ I <br />al>, <br />y c N <br /> <br />10 <br /> <br />C) <br /> <br />E W <br /> <br />N a <br /> <br />Iverzze 15 ?q Tu ?? Signatl <br /> <br />Match <br /> <br />(Name, Location, Interval, etc) <br />Date <br />Time <br />c <br />y <br />(a <br />CIS d rn <br />~ z M <br />Pd C <br /> MATRIX a Cr ez A, L <br /> 1 Dis-001A 8/17110 8hr <br />composite water ? ? ? ® Stop at 13:45 <br /> 2 <br />? <br />? <br />? <br />? <br />? <br /> <br />C: <br /> <br />r <br /> <br />E <br /> <br />M <br /> <br />Species Name <br /> 3 ? ? ? ? ? Species Name <br /> s ? ? ? ? ? Species Name <br /> 5 ? ? ? ? ? r- c q r- -9 Species Name <br /> 6 ? ? ? ? ? Species Name <br /> ? ? ? ? ? Species Name <br /> a ? ? ? ? ? Species Name <br />a <br />m e ? ? ? ? ? Species Name <br />a 10 ? ? ? ? ? Species Name `UU <br /> Custody Relinquished by: Bob Tennant Daterrime: 8/17/10-17;00 Shipped by: t° Received by: Daterrime: <br /> Record MUST Relinquished by: Date/Time: Shipped by: Received by: fY /q -t7 <br />Date/Time: <br /> be Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br /> Sample Tvoe # of fractions <br />In certain circumstances, samples submitted to Energy Laboratories, Inc. may be subcontracted to other certified laboratories in order to complete the analvsis requested. This serves <br /> as notice of this possibility. All sub-contract data <br />will be clearly notated on your analytical report.