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Chain of Custody and Analytical Request Record <br />XIM - PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 2 of 2 <br />Company Name: Cotter Corporation Project Name: Schwartzwalder <br />Tracking No. 3692013 00179537 Water Monitoring Program <br /> REF #/ DATE: 8117/2010 <br />Report Mail Address: Contact Name: Kristy Usnick Sampler Name if other than Contact: <br />Canon City, Mill 1-719-275-7413 EX 213 Bob Tennant <br />PO Box 1750 81215-1750 <br />Invoice Address: Invoice Contact & Phone Purchase Order ELI Quote #: <br />Canon City Mill Kristy Usnick 2563 <br />PO. Box 1750 81215-1750 1-719-275-7413 EX 213 <br />POTW/WWTP ? DW <br />Report Required For Notify ELI prior to RUSH sample Receip <br />. <br />Other s? s submittal for additional charges and JILC <br />ort Formats - ELI must be notified prior to <br />ecial Re <br />S 2 <br />8l scheduling oler <br />p <br />p .. o ,; a g <br />sample submittal for the following: y = Comments: <br />NELAC El A2LA El Level IV ? <br />Other <br />I3 3m' <br />Extended Custoc <br />Intact <br />EDD/EDT Format Q w Signatl <br /> i <br />i <br />i 'o W U) <br />Table 1 <br />Match <br />SAMPLE IDENTIFICATION Collection Collection Z <br />' S ; N N <br />(Name, Location, Interval, etc) Date Time j ? U) 01 L <br /> MATRIX <br />SWAM 8/17/2010 13:00 Water ? ? ? <br /> ? ? ? ? ? _ <br /> ? ? ? ? ? <br /> ? ? ? ? ? <br /> ? ? ? ? ? <br /> ? ? ? ? ? 0 <br /> ? ? ? ? ? <br /> ? ? ? ? ? t <br /> ? ? ? ? ? 1 1- 1: c <br /> ? ? ? ? ? 11 SHAFT-800FT 7/22110 17:40 <br /> Relinquished by: Bob Tennant Date/Time: 8/17/10-17:00 Shipped by: Received by: C Date/Time: <br />Custody <br />Record MUST <br />Relinquished by: DatelTime: <br />Shipped by: <br />Received by: IU ) - Date/Time: <br />be Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions <br />In certain circumstances, samples submitted to Energy Laboratories, Inc. may be subcontracted to other certified laboratories in order to complete the analysis requested. This serves <br /> as notice of this possibility. All sub-contract data <br />will be clearly notated on your analytical report.