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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 />T <br />`Q <br />0 <br />co <br />Company Name: Cotter Corporation Project Name: Schwartzwalder Water Monitoring Program - b1iiharge <br />Tracking No. _3692013___.00179605 DATE: _9/1110 SSTF: S25226 <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 i T <br />R <br />Report Required For: POTWNVVVrP ? RUSH sample ec <br />?p <br />Other <br /> <br /> <br />pecial Report Formats -ELI must be notified <br />S <br /> <br /> <br />. <br /> <br />g submittal for <br /> <br /> <br />a additional charges CC I <br /> <br />r ID(s) <br /> <br />L <br />le submittal for the following <br />rior to sam o <br />?' o t and scheduling <br />y <br />p <br />p b g a Seal <br />Custod <br />NELAC ? A2LA ? Level IV ? ° ° to Comments: cy/ N <br />Other <br />EDD/EDT (] Format 3 <br />a <br />z o <br />y <br />' <br /> <br />a <br /> <br />o <br />E <br />~ Q <br />S&A Schedule Code : <br />DIS CODE #4 <br />intact. <br />t ( / N <br /> t3 g w a € i Signature <br />SAMPLE m 0 Frequency: 2 / N <br />IDENTIFICATION Collection Collection Mat?h LAB ID <br />(Name, Location, Date Time s Y / N <br />Interval etc I MATRIX <br />DIS-001A i 9/1110 com hrsite water ? ® ® ? ? ? ? ? ? ? ? 0 15 rai ???` <br />2 ? ? ? ? ? ? ? ? ? ? ? ? <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? '. <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? <br /> <br />? <br />1 <br />e ? ? ? ? ? ? ? ? ? ? ? a <br />s ? ? ? ? ? ? ? ? ? ? ? ? '?fi % 0 SJ <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br />C <br />t <br />d Relinquished by: Bob Tennant Daterrime: 9/1/10 Shipped by: Received by: Date/Ti <br />us <br />o <br />y 17:aa <br />Record Relinquished by: Date/Time; Shipped by: Received by: Date/Time: <br />MUST be <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY i <br />Sam le T e # of fractions <br />