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v <br />CD <br />N <br />O <br />0 <br />N <br />N <br />CI?ERGY? <br />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 />Company Name: Cotter Corporation Project Name: Schwart welder Water Monitoring Program - Dbchar+pa <br />Tracking No. 369201300179711 DATE: -10/1/10 SSTF: 525415 <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 Tem <br /> <br />l p <br />p <br />Report Required For. POTWA WVTP ? e <br />RUSH samp 11 vg-v'4 C <br />Other <br />ELI must be notified <br />i <br />l R <br />t <br />S <br />t F submittal for <br />additional charges <br />Cooler ID(s) <br />a <br />orma <br />s - <br />pec <br />epor .. o <br />> Q <br />to sample submittal for the following: 1 <br />m t and schedulin <br /> ~' CustodySeal <br />? Level IV 11 <br />NELAC (3 A2LA <br />Oth Comments: Y <br />er <br />EDD/EDT ? Format <br />a <br />a <br />3 <br />~ <br />E <br />S&A Schedule Code : <br />Intact <br />YIN <br /> i ° o <br />°D DIS CODE #table 3 nature <br />Si <br />SAMPLE <br />N = <br />N <br /> <br />Frequency b g <br /> <br />Y / N <br />IDENTIFICATION Colledbn Collection Match LAB ID <br />(Name, Location, Date Time Y I N <br />Interval etc MATRIX F <br />DIS-001A 1011110 8hr Water ? ? ? ® ? ? ? ? ? ? ® ? <br /> <br />2 ? ? ? ? ? ? ? ? ? 01 0 ? <br />3 ? ? ? ? ? ? 0 101 0 ? ? ? <br />4 ? ? ? ? ? ? ? O ? ? ? ? <br />8 ? ? ? ? ? ? ? ? ? ? ? ? <br />6 ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />s ? ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? ? ? ? ? ? <br />76 ? ? ? ? ? ? ? ? ? ? ? ? <br /> <br />tod <br />C Relinquished by: Bob Tennant Daterrime: 10/1/10 <br />Shipped by: <br />Rece ved Date/rime. <br />y <br />us 15:30 <br />Record <br />MUST be Relinquished by: Date/Time: Shipped by: Received by: Daterrime: <br /> <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions