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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 />m <br />co <br />(D <br />v <br />0 <br />co <br />company Name: Cotter Corporation Project Name: Schwartzwalder Water Monitoring Program - DNduwge <br />Tracking No. _389201300179780 DATE: _10/19/10 SSTF: S25416 <br />Report Mail Address: Sampler Name if other than Contact <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick 1-303-642-3893 Schwartzwelder <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 A ELI Quote #: <br />PO Box 1750 Tel: 1-719-2 75-7413 ext. 213 <br />Canon City, CO 81215-1750 Fax: 1-719-275-1669 <br />Notify ELI prior to <br />Report Required For. POTWIWWTP RUSH sample Receipt Temp <br />Other F submittal for g ' C <br />Special Report Formats -ELI must be notified 'b go Q additional charges C ler ID(s) <br />prior to sample submittal for the following: to g t and scheduling 'F <br />Level IV ? d y Custody eal <br />NELAC ? A2? ? z3 ? Comments: Y / <br />All Other a e (ry/ <br />EDD/EDT ? Format S&A Schedule Code : Intact <br />x ' DIS CODE 114 Y / N <br />SAMPLE c x Signature <br />r °_° Frequency: 4 Y / N <br />IDENTIFICATION Collection Collection <br />(Name, Location, Date Time r i Match LAB ID interval etc MATRIX F- 12 YIN <br />DIS-001A 10/05/10 composite 8hr water ? ® ® ? ? ? 010 D D ? ® 15 turn around >- <br />407/ <br />2 a ? 13 ? ? ? ? ? ? ? ? ? <br />3 ? ? ? ? ? ? ? ? D ? 0 ? <br />O ? D TE <br />4 D ? ? E3 ? 13 ? [3 5 D ? ? ? ? ? ? ? ? <br />6 CI ? ? E3 ? ? ? ? 0.0.03 0 <br />13 ? ? ? ? ? ? ? 0 ? ? ? <br />8 ? ? ? ? ? ? ? D ? ? 010-1 <br />9 ? ? a ? 0 D ? ffr-3 ? ? ? ? <br />D?? D 0? D D?? O <br />io <br />Relinquished by: Bob T?rtnant DateTiime: 10119110 Shipped by: <br />Received by: Date/Time: <br />17:30 <br />Rehriquisheo by: Datefrime: Shipped b C Recei `'/ <br />Return to Client ? Leti Disposal ® .!ORATORY USE ONLY . <br />?R' Disposal: Sam # of fractionsfi(_ _