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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 2 of 3 <br />iv <br />cn <br />CD <br />N <br />0 <br />N <br />0 <br />Company Name: Cotter Corporation Project Name: Schwartzwaider <br />Tracking No. 3692013 00179483 Water Monitoring Program <br /> REF #/ DATE: 8/10/10 <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 Quote #: <br />CANON CITY, MILL Kristy Usnick 2563 <br />PO BOX 1750 81215-1750 1-719-275-7413 @EX 213 <br />Report Required For: POTWNVI/WTP ? DW Notify ELI prior to RUSH sample R p T p <br /> F es a <br />bmittal for additional char nd 46Ls <br />Other <br />Special Report Formats - ELI must be notified prior to e a <br />2 .. <br />-8i <br />o <br />t g <br />su <br />a schedulin -C <br />Co <br />r ID(s) <br /> o I <br />sample submittal for the following: <br />NELAC 71 A2LA El Level IV El 1 g <br />m T <br /> <br />-g .2 <br /> <br /> <br />° $ Comments: <br /> <br /> <br />ustody SealY <br /> <br />Other c* <br />61 <br />a *1 8 <br />Intact Y N <br />EDD/EDT Format Signature Y N <br /> <br />SAMPLE IDENTIFICATION <br />Collection <br />Collection x I a w = Match <br />(Name, Location, Interval, etc) Date Time <br />MATRIX <br />> <br />> <br />0: <br />0: <br />, <br />Z <br />a <br />LAB ID <br />SW-BDSI 8/10/10 13:35 Water [E] 0 C 1: Species Name <br />SW-PL 8/10/10 14:13 Water Species Name <br />SW-OS 8/10/10 14:30 Water Species Name <br />SW-80S 8/10/10 14:45 Water 0 1: 1: r Species Name <br />SW-GS 8/10/10 15:00 water E: r Species Name <br />SW-AWD 8/10/10 12:45 Water Species Name <br />SW-A001 8/10/10 13:11 Water <br />- Species Name <br />SW-BPL 8/310/10 15:10 water <br />r <br />9 <br /> <br />Species Name <br /> Species Name <br /> Species Name <br /> Relinquished by: Bob Tennant 8/10/0917:00 Date/Time: Shipped by: Received by: Date/Time: <br />Custody <br />Record MUST Relinquished by: Date/Time: Shipped b a • e Received b : /hp Daterrime, i <br />be Signed <br />Sample Disposal: <br />Return to Client ? Lab Disposal ® LABORATORY USE ONLY <br />Sample Type # of fractions <br />1 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.