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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 />T <br />N <br />CD <br />N <br />O <br />0 <br />N <br />CA) <br />Company Name: Cotter Corporation Project Name: Sehwartzwolder Water Monitoring Program - DleCher" <br />Tracking No. 369201300179803 DATE: _10/26/10 SSTF: 525247 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick 1-303-642-3893 Schwartzwalder <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 R <br />i <br /> <br />Report Required For: POTWIWWTP ? <br />RUSH sample pt ,Temp <br />ece <br />- <br /> <br />Other <br />Special Report Formats - ELI must be notified <br /> <br />.. e <br />F <br />submittal for <br />c additional charge T C <br />Coo 101s) <br />s <br />prior to sample submittal for the following: m t and scheduling Custody Seal <br />NELAC ? A21 -A ? Level IV ? <br />Other y - Comments: Y <br />v <br /> <br />EDD/EDT [I Format <br />a c <br />r <br />~ e <br />E SBA Schedule Code : <br />Intact <br />Y / N <br /> ,? DIS TABLE #3 <br />SAMPLE <br />a 0 <br />z = <br />Frequency: 4 Signature <br />Y/ N <br />IDENTIFICATION <br />i <br />N <br />L Collection <br />D <br />t Collection <br />Ti Match LAB ID <br />on, <br />( <br />ame, <br />ocat a <br />e me _ F Y / N <br />Interval etc MATRIX <br />DIS-001A 10426/10 8 hr posite Water ? ? ? ® ? ? ? ? ? ? ? ® 15 day turn around <br />(I Jo /0( <br />2 ? ? ? ? ? ? ? ? ? ? ? ? <br />3 D ? ? ? ? ? ? ? ? ? ? ? <br /> ? ? ? ? ? ? ? o o ? ? ? <br />5 ? ? ? ? ? ? ? ? ? ? ? ? <br />e ? D D ? ? O 0, 0, 0 0 O D <br /> ? ? ? ? ? O ? ? O O ? ? <br />e ? ? ? ? ? ? ? ? ? ? D <br />s ? ? ? ? ? ? D D ? ? ? ? <br />+o ? [31 0 ? ? ? O ? ? ? ? ? <br /> <br />Custod Relinquished by: Bob Tennant Date/Time: 10126/10 Shipped by., ?X Received b . <br />te/Time: ff <br />y 17.30 <br />Record <br />MUST be Relinquished by: Date/Time: Shipped by: Received by: Datelrime: <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />S <br />l <br />T <br />i <br />f f <br /> amp <br />e <br />ype # o <br />ons <br />ract