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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 />W <br />C.n <br />0 <br />.A <br />Company Name: Cotter Corporation Project Name: Schwartzwalder Water Monitoring Program - <br />Tracking No. 3692013 00179575 two coolers DATE: _8/2510 SSTF: S 25177 --- S25184 <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 Recei <br />t <br />em <br /> <br />Report Required For: POTWNVWTP ? <br />RUSH sample p <br />T <br />p <br />C <br />Other <br />Special Report Formats -ELI must be notified <br />prior to sample submittal for the following: <br /> <br />o 0 <br /> <br />w <br /> <br />c <br />° <br />0 <br />U <br />a <br />t <br />g submittal for <br />F additional charges <br />and schedulin <br />CoolerJD(s) <br />11 <br />- - <br /> > o o w <br />C <br />t Customs Seal <br />NELAC ? A&A ? Level IV ? s 1" o <br />U u 2 m e ommen <br />s: y N <br />Other <br />EDD/EDT El Format 3 <br />E a$i o <br />c t <br />W M a <br />S&A Schedule Code: <br /> <br />Intact <br />N <br />CY <br /> z <br />11 o its <br />= <br />= <br />SW CODE 11 , <br />Sign ture <br /> < € <br />SAMPLE <br />;r o z° Frequency 1,4 Li?/ N <br />IDENTIFICATION Collection Collection am[ N < 2 coolers 00179582 Match LAB ID <br />(Name, Location, Date Time I ?` <br />? w <br />N <br />Y! N <br />Interval etc MATRIX = <br />SW AWD 8/24110 12:40 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />2 SW A001 8/24/10 13;00 Water ® ? ? ? ? ? ? ? ? ? 0 ? Code I <br />3 SW BDIS 8/24110 14:10 Water ? ? ? 0 ? ? ? ? ? ? 0 ? Table 1 <br />4 SW PL 8/24/10 16:03 Water ? ? ? 0 ? 0 10 10 ? ? ® ? Table 1 <br />s SW OS 8/25110 9;05 Water ? ? ? 10 10 ? ? ? ? ? ® ? Table 1 <br />6 Sw SOS 8125110 12:00 Water 0 ? ? ? ? ? ? ? ? ? 0 ? Code 1 <br />SW GS 8125/10 12;14 Water ® ? ? ? ? ? ? ? ? ? 0 ? Code 1 <br />e SW BPL 8/25/10 12:48 Water 0 ? ? ? ? ? ? ? ? ? 0 ? Code 1 <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? ? ? ? <br />Custody Relinquished by: Bob Tennant Daterrime: 14:30 Shipped by: Received by: DateMme:9 3 /O <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 <br />Sample Type # of fractions <br /> <br />,Vd