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AMU 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: Schwarb waider Water Monitoring Program - <br />Tracking No. 3692013 00179759 DATE: _10/13/10 SSTF: S 25270 --- S25274 <br />Report Mail Address: Sampler Name if other than Contact: <br />Cotter Corporation - Canon City Mill Contact Name: Kristy Usnick 1-303-642-3893 mine phone <br />PO Box 1750; Canon City, CO 81215-1750 Voice: 1-719-275-7413 ext. 213 Bob Tennant 1-719-371-3009-cell <br />Invoice Address: Invoice Contact Kristy Usnick Purchase Order #: ELl 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 i Tem <br />R <br /> <br />Report Required For: POTWIWVVTP ? <br />RUSH sample p <br />ece <br />, <br /> <br />Other <br />Special Report Formats - ELI must be notified <br /> <br />* <br /> <br />a <br />submittal for <br />F additional charges C <br />Cooler ID(s) <br />prior to sample submittal for the following: Am > o 9 and schedul- <br /> Custody Beat <br />NELAC ? A2LA [3 Level IV El <br />Other s y <br />< a m <br />g Comments: Y <br /> <br />EDD/EDT [I Format •9 <br />, <br />- $ 1 <br />9 <br />a E E <br />E S&A Schedule Code Intact <br /> z 5 - ' S W CODE 11 <br />s Y I N <br />ture <br />Si <br />n <br />SAMPLE <br />I <br />E ? <br />aim <br />°e Table 1 <br />Frequency 1,2,3,4 g <br />a <br />YIN <br />D <br />NTIFICATION Collection Collection Match LAB ID <br />(Name, Location, Date Time V Y I N <br />Interval etc MATRIX <br />SW AWD 10/12/10 12:10 Water ? ? ? ® ? ? ? ? ? ? ® ? TABLE 1 <br />SW A001 10/13/10 9:10 Water ? 17 ? ® ? ? ? ? ? ? ® ? TABLE 1 <br />3 SW BDIS 10/13/10 10:28 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />4 SW PL 10/13/10 10:45 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />3 SW OS 10/13/10 12;20 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />E SW BOS ? ? ? ? ? ? ? ? ? ? 13 ? no sample <br />SW GS ? ? ? ? ? ? ? 13 [3 El ? ? no sample 1010 <br />a SWBPL ? ? ? ? ? ? ? <br />? 11 [3 13 13 no sample <br />9 ? ? ? ? ? ? ? 13 ? ? ? ? <br />10 ? ? ? ? 13 0 ? ? ? ? <br /> <br />Custod Relinquished by: Bob T n nt Da t i e:10/13110 Shipped by: <br />pP? y' Received b Date/Time: , <br />y' loe <br />y 15:30 0 o <br />Record <br />MUST be Relinquished by: Daterrime: Shipped by Received b i <br />Signed Sample Disposal: Return to Client ? Lab Disposal ® <br />Sam 0 of ??b <br />RATORY U Orfft?Lw!fions!n <br />