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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 />d <br />Company Name: Cotter Corporation Project Name: ScF?wartzwaslder Water Monitoring Program - <br />Tracking No. 3892013 00179728 DATE: _10105/10 SSTF: S 252 42 --- S25244 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill <br />7 Contact Name: Kristy Usnick <br />213 <br />1-719-275-7413 ext <br />i <br />V 1-303-642-3893 mine phone <br />Bob Tennant 1-719-371-3009-Cell <br />50 <br />PO Box 1750; Canon City, CO 81215-1 . <br />o <br />ce: Purchase Order ELI Quote <br />Invoice Address: Invoice Contact: Kristy Usnick <br />PO Box 1750 Tel: 1-719-275-7413 ext. 213 <br />Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br /> Notify ELI prior to Receipt Temp <br />Report Required For: POTW/IM/IrrP El <br />Other ? <br />F RUSH submittal for sample <br /> <br />es <br />har <br />l <br />dditi C <br />Cooler ID(s <br />rt Formats - ELI must be notified <br />l R <br />S <br />i g <br />c <br />ona <br />4 a 014 <br />epo <br />pec <br />a <br />prior to sample submittal for the following: a w .- <br />e and schedulin <br />Comments: <br />Neal <br />Custod <br />NELAC ? A2LA ? Level IV ? 3 $ a 9 I <br />Intact (? <br />Other <br />EDDIEDT ? Format 4 r o 1- S&A Schedule Code: <br />SW CODE 11 YIN <br /> <br />$ re <br />Signatu <br />SAMPLE <br />' Frequencyf 1 YIN <br />tch LAB ID <br />M <br />IDENTIFICATION Collection Collection a a <br />(Name, Location, Date Time Y I N <br />Interval etc MATRIX <br />' SW AWD 10105/10 9:30 Water ® ? ? D ? ? ? ? ? ? ® ? CODE 1 <br />1 SW AoO1 ? ? ? D ? ? ? D ? ? ? ? Dry no sample _ <br />3 SW BDIS ? ? ? ? ? ? ? ? ? ? ? D Dry no sample <br />SW PL ? ? ? D ? ? ? ? ? ? ? ? <br />no sample <br />Dry <br />5 SW oS ? ? ? D ? ? ? ? ? ? ? ? Dry no sample <br />5 [3 ? D ? D [3 ? ? ? ? [3 ? Dry no sample <br />Sw BOS <br /> W <br />t ® ? ? ? ? ? [1 0 ? ? ® ? CODE 1 <br />SW GS 10105110 10:40 a <br />er , <br /> W <br />t ® ? ? ? ? ? ? ? ? ? ® ? CODE 1 <br />e SW BPL 10/05/10 11:04 er <br />a <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />y <br />,n ? ? ? ? ? ? n ? ? ? ? ? <br /> Relinquished by: Bab Tennant DatelTime:1015110 Shipped by: <br />F Received by: DaterTime: lo1a?l0 <br />Custody 15:30 <br />Record <br />MUST be <br />Relinquished by: Datelrime: Shipped by: <br />Rece' ed by. <br />LA RATORY USE LY <br />Signed Semple Disposal: Return to Client E3 Lab Disposal ® Sa # of fractions <br />t5