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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 />v <br />Company Name: Cotter Corporation Project Name: Schwarfzwalder Water Monitoring Program - Discharge <br />Tracking No. 3692013_00179667 DATE: _9/14/10 SSTF: S25464 <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 POTW/WVVrP ? <br />8 <br />RUSH sample Rece <br />Temp <br />a <br />Other <br /> <br />Special Report Formats - ELI must be notified a <br /> <br />.. o <br />? <br />?? <br /> <br />¢ submittal for <br /> <br />r= additional charges <br />o C er u(s) <br />C <br />prior to sample submittal for the following. m o and scheduling <br />t <br />C <br />d <br />S <br />NELAC ? A2LA ? Level IV ? m y y o Comments: usto <br />y <br />eal <br />Y <br />/ fl <br />Other <br />EDD/EDT El Format 3 <br />E ` a o <br />y <br />m <br />F Q <br />E S&A Schedule Code : / <br />, <br />intact L? <br /> Z DIS CODE Y / N <br />SAMPLE 8. € <br />° <br />5 <br />F Signature <br />IDENTIFICATION Collection Collection a' N LU r z M requency: Y / N <br />(Name, Location, Date Time o N c Match LAB ID <br />Y / N <br />Interval etc MATRIX ' <br />DIS-001A 918/10 8hrsite <br />compo Water El ? ? ® ? ? ? ? ? ? ? ® 15 day turn around <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? a ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />e ? ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />Custody Relinquished by: Bob Tennant DatelTime: 9/14/10 <br />Shipped by. <br />Received by: Date/Time: ?• (?j l(' <br /> 17:00 <br />Record <br />MUST be <br />Relinquished by' Date/Time: <br />Shipped by: <br />Received by: Daterrime: <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USEONLY <br /> Sample T # of <br />