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Chain of Custody and Analytical Request Record <br />®?Tr?°'? PLEASE PRINT; provide as much information as <br />possible. Refer to corresponding notes on reverse side. Page 2 of 2 <br />Company Name: Cotter Corporation Project Name: Schwartzwalder <br />Tracking No. _3692013 00179391 Water Monitoring Program <br />3692013 00179407 <br /> REF #/ DATE: 712212010 <br />Report Mail Address: Contact Name: Kristy Usnick Sampler Name if other than Contact: <br />Canon City, Mill 1-719-275-7413 EX 213 Susan Wyman, 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 /> <br />Report Required For: POTWNWVTP ? DW Notify ELI prior to RUSH sample i <br /> <br /> <br />Other <br />e e <br />submittal for additional charges and Re <br />F <br /> <br />Special Report Formats - ELI must be notified pr ior to F .. o a o a scheduling C <br />ler <br />sample submittal for the following: _m g t Comments: oo <br />Z?s2 <br />NELAC ? A2LA ? Level IV ? a N a a >? r Custoc <br />Other a W Extended Mine Pool suite Intact <br />EDD/EDT <br />Format <br /> <br />i a <br />a <br />12 <br />E <br />' Si <br />nat <br /> t o to N E t- See final comment for sample #11 g <br />Match <br />SAMPLE IDENTIFICATION Collection Collection 8 0 n N 8 ID, date, and time <br />(Name, Location, Interval, etc) Date Time & ? V W L <br /> MATRIX W <br />SHAFT-3FT 7/22/2010 12:10 W ? ? ? <br />2 SHAFT-25FT 7/2212010 12:40 W ? ? ? ? 0 <br />SHAFT-SOFT 7/22/2010 12:55 W ? ? ? ? <br />SHAFT-10OFT 7/22/2010 13:50 W ? ? ? ? <br />SHAFT-20OFT 7/22/2010 14:20 W ? ? ? ? <br />E <br />SHAFT-300FT 7122!2010 14:50 W ? ? ? ? <br />i <br />7 SHAFT-40OFT 7/22/2010 15:20 W ? ? ? ? E J <br />e SHAFT-506FT 7/22/2010 16:10 W ? ? ? ? <br />s SHAFT-6WFT 7/22(2010 16:30 W ? ? ? ? ® - <br />10 SHAFT-70OFT 7!22/2010 16:50 W ? <br />1 ? <br />? <br />? <br />® <br />11 SHAFT-80OFT 7122/10 17:40 <br />C Relinquished by: Bob Tennant Date/Time: 7/22/10- 18:00 Shipped by: Received by OateTme: <br />ustody <br />Record MUST Relinquished by: Date/Time: Ship ped by: Received by: . 2(;., tO'Q%tC) Datemme: <br />be Signed <br />Sample Disposal: <br />Return to Client ? Lab Disposal ® LA TORY USE ONLY <br /> Sample T # of fractions <br /> <br />In certain cirwmstances, samples submitted to Energy Laboratories, Inc may be subcontracted to other certified laboratories in order to complete the analysis requested. This serves as <br /> notice of this possibility- All subcontract data <br />will be oleady rota 4 on your unalyticol report.