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J5MA MR Chain of Custody and Analytical Request Record <br />WEST! PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 2 of 3 <br />Company Name: Cotter Corporation Project Name: Schwartzwalder <br />Tracking No. 3692013 00179452 Water Monhoring Program <br /> REF #1 DATE: 813110 <br />Report Mail Address: Contact Name: Kristy Usnick Sampler Name if other than Contact: <br />CANON CITY, MILL 1-719-275-7413 @EX 213 Bob Tennant <br />PO BOX 1750 81215-1750 <br />Invoice Address: Invoice Contact & Phone Purchase Order* ELI Q uote <br />CANON CITY, MILL Kristy Usnick 2563 <br />PO BOX 1750 81215-1750 1-719-275-7413 @EX 213 <br />Report Required For: POTWNVWTP ? DW Notify ELI prior to RUSH sample Receipt Temp <br />Other <br />ort Formats - ELI must be notified pr <br />ecial Re <br />S <br />ior to e <br />A <br />a F <br />t submittal for additional charges a <br />¢ scheduling nd IV C C <br />Coo <br />p <br />p 0# <br />7 <br />Comments: l <br />sample submittal for the following: <br />NELAC ? A2LA ? Level IV ? H < 3 Custody SeaL9 <br />Intact Y <br />Other <br />EDDlEDT Format E Signature Y(V <br /> <br />DENTIFICATION <br />ll <br />ti <br />C <br />C <br />ll <br />ti I '? $ <br />c = Match <br />SAMPLE I ec <br />on <br />o o <br />ec <br />on >i z <br />(Name, Location, Interval, etc) Date Time MATRIX > > °? LAB ID <br />SW-BOSI 8/3/10 13:10 Water TJ -d Specles Name <br />SW-PL 8/3/10 13:30 Water Species Name <br />SW-OS 8/3/10 13:50 Water <br />c <br />17 <br />R <br /> <br />Species Name <br /> <br />SW-130S 8/3/10 14:25 Water Species Name <br />SW-GS 8/3/10 15:12 water Species Name <br />SW-AWD 8/3/10 11:50 Water Species Name <br /> <br />SW-A001 8/3/10 12:30 Water r- il 0 1: r- c: r- r- c [1 9 Species Name <br />SW-13131- 8/3/10 15:30 water 1: C r- r- r- C C Species Name <br /> Species Name ' <br /> Species Name <br /> Relinquished by: Bob Tennant 8/310912:00 Date/Time: Shipped by: Received by: Date/Time: <br />Custody <br />Record MUST <br />Relinquished by: Date/Time: <br />Shipped by: <br />Received by: <br />Date/Time:,a -S 10 131 <br />be Signed <br />Sample Disposal: <br />Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type #of fractions <br />In certain circumstances, samples submitted to Energy Laboratories, Inc. may be subcontracted to other certified laboratories in order to complete the analysis requested. This serves <br /> as notice of this possibility. All sub-contract data <br />will be clearly notated on your analytical report.