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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 />rn <br />0 <br />rn <br />Company Name: Cotter Corporation Project Name: Schwartrwalder Water Monitoring Program - umnarge <br />Tracking No. 369201300179711 DATE: x9130/10 SSTF: S25414 <br /> Sampler Name if other than Contact: <br />Report Mail Address: <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 />Q) Notify ELI prior to Receipt Temp <br />Report Required For: POTWNVWTP ? RUSH sample 11 l?° C <br />Other <br /> <br />tifi <br />d LO <br />d F <br />¢ submittal for <br /> <br />additional charges <br />F Cooler ID(s) <br /> <br /> <br />} <br />3 <br />e <br />Special Report Formats -ELI must be no = 9- <br />0 $ t and scheduling .s .c1 <br />prior to sample submittal for the following: <br />C ? A2LA ? Level IV El 2 <br />y <br />?? ' <br />sn o _ g <br />Comments: Custody Seal <br />Y <br />NELA <br /> <br />Other E -Z <br /> <br />as _ <br /> <br />I <br />iA <br /> <br />E <br />C <br /> <br />S&A Schedule Code : <br /> <br /> <br />ntact <br /> <br />EDD/EDT Format <br />(] 0l <br /> <br />= <br /> <br />m <br /> <br />o <br /> <br />E <br /> <br />DIS CODE 02 <br /> <br />Y/ N <br /> ? EE = Signature <br />SAMPLE I = . M z ' :03 Frequency: _1 Y / N <br />IDENTIFICATION Collection Collection gym' F4 Match LAB iD <br />(Name, Location, Date Time o s 0 <br />e M <br />? <br />~ Y/ N <br />Interval etc MATRIX <br />DIS-001A---A 9/28/10 compo ite Water ® ? ? ? ? ? ? ? 13 ? ® ? <br /> <br />2 DIS-001A B 9129110 Bhr water ® p ? ? 13 <br />? <br />? <br />G <br />? <br />a <br />® <br />? <br /> <br />Composite - <br />001A-C <br />3 DIS 9/30/10 8hr water 0 ? 13 ? 11 11 ? ? ? ? ® ? <br />- tO <br />6 ? ? ? ? ? ? ? ? ? ? D ? <br /> <br /> <br /> e ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> e <br />s n ? o ? ? ? ? ? ? ? ? ? ?o1Q''l5 <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br /> 10 <br />Relinquished by: Bob Tennant Date/Time: 10/1110 <br />Shipped by: Receiv b DateTme?ca , <br />y: cs a <br /> Custody 15:30 <br /> Record Relinquished by: Date/Time: Shipped by: Received by: Date/rime: <br /> MUST be <br />Signed Sample Disposal: Retum to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sam le Type # of fractions