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Amu 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 />v <br />(D <br />0 <br />co <br />Company Name: Cotter Corporation Project Name: Schwarbiwalder Wafer Monitoring Program - Discharge <br />Tracking No. _3892013_00179728 DATE: _10/05/10 SSTF: S25241 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick 1-303-642-3893 Schwarizwalder <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant 1719-371-3009 <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 Receipt Tamp <br />Report Required For. POTW/WWTP ? RUSH sample 2"1 im <br />Other <br />t <br />ELI <br />t b <br />tifi <br />d <br />t F <br />R a submittal for <br />additional charges C ler 14(s) <br /> <br />f <br />orma <br />mus <br />e no <br />e <br />Special <br />epor <br />s - .. o <br />l a <br />and scheduling ? <br />t <br />prior to sample submittal for the following: <br />1 Level IV ? <br />NELAC ? QLA F m - <br />J <br />- <br />y <br />4 t <br /> <br />Comments: stody al <br />- <br />Other <br />EDD/EDT ? Format -6 <br />3 <br /> <br />S&A Schedule Code . <br />IS CODE #4 / <br />Y <br />Intact <br />Y / N <br /> D <br />X Signature <br />SAMPLE 9 z Frequency: _4 Y / N <br />ION <br />IDENTIFICAT Collection <br />D <br />t Collection <br />Ti Match LAB ID <br />(Name, Location, a <br />e me Y / N <br />Interval etc MATRIX <br />DIS-001A 10/05/10 8hr Water ? ® 19 ? ? ? ? ? ? ? 0 ? <br /> composite <br />2 ? ? ? ? ? ? ? ? ? ? ? ? <br />3 ? ? ? ? ? ? ? ? ? ? ? ? <br />4 ? ? ? ? ? ? ? ? ? ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />7 ? ? ? ? ? ? ? ? ? ? ? ? <br />Z <br />CA3 <br />e D O ? ? ? ? ? ? ? ? ? ? <br />9 ? ? O 0 10 ? ? ? ? ? D ? <br /> <br />io <br />O <br />? <br />O <br />? <br />? <br />O <br />? <br />? <br />? <br />? <br />? <br />? 1 <br />t <br />d <br />C Relinquished by: Bob Tennant Daterrime: 10/05/10 Shipped by: F' <br />d Received by: Date/Time: <br />o <br />us <br />y 15:30 e <br />Record <br />MUST b <br />Relinquished by: Date/Time: <br />Shipped by: <br />R &i b . i <br />e <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® ORATORY U ONLY <br />Sam T *of tractions <br />i)