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v <br />CD <br />N <br />O <br />0 <br />N <br />N <br />E/?CRGY <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: Schwartzwalder Wafter Monitoring Program - Discharge <br />Tracking No. 3692013,"00179759 DATE: _10/13/10 SSTF: 525269 <br />Report Mail Address: <br />Cotter Corporation - Canon City Mill <br />Contact Name: Osty Usnick Sampler Name if other than Contact: <br />1-303-642-3893 Schwartzwalder <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant 1 719-371-3009 <br />Invoice Address: <br />PO Box 1750 Invoice Cont#ct: Kristy Usnick Purchase Order ELI Quote <br /> <br />Canon City <br />CO 81215-1750 Tel: 1-719-n5-7413 ext. 213 <br />, Fax: 1-719-275-1669 <br /> Notify ELI prior to <br /> <br />Report Required For: POTW/WWTP ? <br />RUSH sample Recei <br />p emp <br /> <br />Other <br />Special Report Formats - ELI must be notified <br />i <br /> <br />, . <br />' <br />? <br />F <br />submittal for <br />a additional charges o <br />C <br />Coo,ele/r <br />ID <br />(s <br />) <br /> <br />pr <br />or to sample submittal for the following: <br />NELAC [I A2LA ? Level IV ? <br />Oth <br />g <br />- <br /> <br /> <br /> <br />" <br />g <br />t and scheduling <br /> <br />Comments: " <br />" <br />" <br />J <br />?.ssc r <br />Custod? <br />er <br />p Y <br />EDD/EDT ? Format °0 a S&A Schedule Code : <br /> <br /> <br />DIS TABLE 3 <br />Intact / <br />N <br />SAMPLE Signature <br /> n o N <br />IDENTIFICATION Collection Collection ??? n w z Frequency: <br />5 <br />Y/ N <br />(Name, Location, Data Time N Mateh LAB ID <br />Interval etc MATRIX a Y / N <br />I DIS-001A 10/05/10 <br /> <br />8hre <br />composit <br /> <br />Water <br /> <br />? <br /> <br />13 <br /> <br />? <br /> <br />® <br /> <br />O <br /> <br />C3 <br /> <br />? <br /> <br />? <br /> <br />? <br /> <br />? <br /> <br />® <br /> <br />[1 <br /> ? D ? ? ? ? ? ? ? ? ? ? <br />9 ? ? D O D ? ? O ? ? ? ? <br /> ? ? D ? ? ? ? ? ? O ? ? - <br />s <br />? <br />? <br />D <br />O <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />6 <br />D <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br />? <br /> D ? ? ? ? ? ? ? ? ? ? ? <br />a D o ? D ? ? ? ? ? ? ? ? <br /> D ? ? ? D ? ? ? ? ? D D <br />10 ? ? ? ? t:7 ? D ? ? ? O D <br /> <br />Custody <br />R Relinquished by: Bob Tennant Date/Time: 10/13/10 <br />15:30 <br />Shipped by: <br />Received by: Date/Time: ?D Q <br />ecord <br />MUST be <br />Relinquished by: Date/Time: <br />Shipped by: r -e . <br />Received by: Datefrime: <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br /> Sample T # of fractions