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M 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 />m <br />N <br />N <br />N <br />O <br />0 <br />N <br />N <br />Company Name: Cotter Corporation Project Name: Schwartzwaider Water Monitoring Program - Discharge <br />Tracking No. _3692013_00179605 DATE: _9/1/10 SSTF: S25227 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant <br />Invoice Address: Invoice Contact: Kristy Usnick Purchase Order#: ELI Quote <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 <br /> <br />Report Required For: PONV/WW TP ? <br />RUSH sample Receipt Temp <br />o C <br />Other <br />Special Report Formats - ELI must be notified a <br />? .. o g <br />7 <br />F submittal for <br />F additional charges - <br />C 1er i0 sI <br />? <br /> <br />p(lbr to sample submittal for the following: <br />NI?LAC ? A2LA ? Level IV ? <br />$m q <br />v <br />o <br />A <br /> <br />o <br />t and schedulin <br />Comments: Q <br /> <br /> <br />Cust y Neal <br />Other <br />EDD/EDT ? Format , <br />E 3 <br />E a a AA 22 <br />0 r <br />a 12 <br />a <br />E M <br />§ <br />SBA Schedule Code : <br />Intact <br /> z c ,? a <br />a DIS CODE 04 / N <br />Si <br />t <br />SAMPLE 0 € N gn <br />ure <br />U <br /> <br />IDENTIFICATION <br />Collection <br />Collection ° <br />m <br />; ^ j Z Frequency: 2 / N <br /> <br />Mapeii LAB ID <br />(Name, Location, Date Time I o ; Q Y N <br />Interval etc MATRIX r <br />' DIS-001A 911/10 Water ? ? ? ® ? ? ? ? ? <br />? <br />? <br />® <br />may/ u <br /> composite ; I 'y <br />2 i ? ? ? ? ? ? ? ? ? ? ? - < <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />- <br />A ? ? ? ? ? ? ? ? ? ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br />e ? ? ? ? ? ? ? ? ? ? ? ? . <br />9 ? ? ? ? ? o ? ? ? ? ? ? <br />,a ? ? ? ? ? ? ? ? ? ? ? ? <br /> Relinquished by: Bob Tennant Date/Time: 9/1110 Shipped by: Received by: Dateffime: <br /> 17:Q0 <br />Record <br />MUST be Relinquished by: Date/Time: Shipped by: Received by: DateMme: 2 <br />Signed Sample Disposal: Return to Client El Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions <br />w <br />0-716