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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 />v <br />CD <br />0 <br />0 <br />Company Name: Cotter Corporation Project Name: Schwartzwaider Water Monitoring Program - <br />Tracking No. 3692013 00179728 DATE: 10/05/10 SSTF: S 252 42 --- 525244 <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 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 Re cej'pt Temp <br /> . m <br />le <br />RUSH _ <br />Report Required For: POTWNVWTP ? J p <br />sa f ; &o C <br />Other <br />Special Report Formats - ELI must be notified <br /> <br />m >i submittal for <br />c additional charges <br />d schedulin C ler iD{s <br />prior to sample submittal for the following: <br />A ? L <br />l IV ? <br />L <br />C El A21 an <br />Comments: Custody ,seal <br />eve <br />NE <br />A <br />- <br />Other ` e 5 Y <br />EDD/EDT [I Format e c ° 2 ue Code <br />S& <br />DE <br />1 <br />Intact <br />I N <br /> = - X <br />1 <br />CO <br />SW Signature <br />SAMPLE s <br />Frequencyt 1 <br />Y / N <br />IDENTIFICATION Collection Collection s Match LAB ID <br />(Name, Location, Date Time Y I N <br />Interval etc MATRIX > <br />' SW AWD 10/05/10 9:30 Water ® ? ? D ? ? ? ? ? ? ® D CODE 1 <br />SW A001 D [3 103 13 11 ? ? 13 ? ? [3 ? Dry no sample <br />3 SW BDIS ? [3 ? ? [3 El [3 [3 [3 [3 ? [3 Dry no sample <br />4 SW PL ? ? ? ? ? ? ? ? ? ? ? ? Dry no sample <br />5 SW OS ? ? ? ? ? ? ? ? ? ? ? ? Dry no sample <br />a SW BOS D ? ? ? ? ? ? ? ? ? ? ? Dry no sample <br />SW GS 10/05/10 10:40 Water ® ? ? ? ? ? ? ? ? ? ® ? CODE 1 <br />a SW BPL 10/05110 11:04 Water 0 ? ? ? ? ? ? D ? ? 0 10 CODE 1 <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? D ? ? ? ? ? D <br /> Relinquished by: Bob Tennant Date/Time:10/5110 Shi d b ((''''''' ,r~ <br />PPe y Received b Date/Time: lQ <br />y' 10?? <br />Custody 15:30 ' re C <br />Record <br />MUST be Relinquished by: Date/Time: Shipped by: Rece' ed by. <br /> <br />Signed <br />Sample Disposal: Return to Client ? Lab Disposal ® MILY <br />LApORATORY USE <br />Sa e T4,101 a # of fractions <br />b