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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 />-o <br />Om <br />U3 <br />CD <br />fn <br />Company Name: Cotter Corporation Project Name: Schwartzwaider Water Monitoring Program - Discharge <br />Tracking No. _3692013_00179698 DATE: 9/22110 SSTF: S25364 <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 61215-1750 Fax: 1-719-275-1669 <br /> Notify ELI prior to <br /> <br />Report Required For: POTWM/Wi P ? <br />RUSH sample Receipt Temp <br /> <br />ID C <br />Other <br />Special Report Formats - ELI must be notified < submittal for <br />F additional charges <br />Cooler ID(s} <br />prior to sample submittal for the following: ? s g t and scheduling <br /> <br />NELAC [] A2LA ? Level IV ? U <br />N a <br /> <br />o <br />S Comments: Custod Sal <br /> <br />Other 13: <br /> <br />E <br />o t: <br />m Y I N <br /> <br />Intact <br />EDD/EDT El Format E S&A Schedule Code : <br /> x ° E DIS CODE #4 YIN <br />SAMPLE si a € <br />z° N <br />Frequency: Signature <br />YIN <br />IDENTIFICATION Collection Collection Match <br />LAB ID <br />(Name, Location, Date Time a <br />Y / N <br />Interval etc MATRIX * '- <br />' DIS-001A 9/8/10 com hrsite Water ? ® ® ? ? ? ? ? ? ? M ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />3 - ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? o ? ? ? ? ? ? - <br />5 ? ? ? ? ? ? ? a ? ? ? ? _ <br />e ? a ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />8 ? ? ? ? ? ? ? ? ? ? ? ? <br />a a ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? O ? ? <br /> <br />Custody Relinquished by: Bob Tennant Daterrime: 9/22/10 <br />15:00 <br />Shipped by: - / <br />Received by. <br />C Daterrime: <br />Record Relin uished b : Daterrime: <br />p Shi <br />ped by: Received by: Date/Time: D; <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LA <br />BORATORY USE <br />O <br />c <br /> # <br />Sample <br />Type <br />a <br />tions <br />7 <br />S