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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 />Company Name: Cotter Corporation Project Name: Schwartzwaider Water Monitoring Program - <br />Tracking No. 3692013 00179797 DATE: _10120/10 SSTF: S 254 1 7---525424 <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 <br />Report Required For: POTWMNVfP ? <br />Other RUSH sample ReceiP emp <br />C <br />Special Report Formats - ELI must be notified <br />0 ' a submittal for <br />i+ additional charges Co r, ID(s) <br />prior to sample submittal for the following: <br />NELAC ? <br />? , 'i <br />A <br />'s <br />> <br /> <br />8 <br /> <br />UJ ro and schedulin Custod <br />Seal <br />A2LA <br />Level IV ? m <br />- o Comments: y <br /> <br />Other <br /> <br />a J <br />< <br />45 Y!N <br />EDD/EDT C1 Format im, W SB,A Schedule Code : Intact <br /> <br />Z <br />°6 <br />x <br />SW CODE I i Y / N <br />SAMPLE I S N Table 1 Signature <br />IDENTIFICATION Collection Collection Frequency! 1,2„4 Y / N <br />(Name, Location, Date Time Match LAB ID <br /> <br />Interval etc <br />MATRIX Y / N <br />' SW AWD 10/20110 9:25 Water ® ? ? ? ? ? ? ? ? ? ® ? codel <br />2 SW AO01 10/20/10 10:05 Water ® ? ? ? ? ? ? O ? ? ® ? Code 1 <br />3 SW BDIS 10/20110 11:15 Water ? ? ? ® ? ? ? 01 0 D ® ? Table 1 <br />4 SW PL 10/20110 12:20 Water ® ? ? ? ? ? ? ? ? ? 19 ? Code 1 <br />5 SW OS 10/20/10 13:35 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1 <br />5 SW BOS 10/21/10 10:15 Water 10 ? ? ? ? ? ? D ? ? ® ? Code 1 b 0i ao. <br />SW GS 100110 11:10 Water ® ? ? ? ? ? O ? ? ? ® ? Code 1 <br />e SW BPL 10121/10 11:50 Water ® ? ? ? ? ? ? ? ? D ® ? Code 1 <br />9 ? ? ? ? ? ? ? ? ? ? ? ? <br />10 ? ? ? ? ? ? ? ? ? O 7 -11-1 <br /> <br />Custody Relinquished by: Bob Tennant Date/Time:10/22/10 <br />16:30 <br />Shipped by: <br />Received by: DatelTime:* <br />Record <br /> <br />MUST be Relinquished by: Daterrime: Shipped by: Receiv y: <br />Signed Sample Disposal: Return to Client E) Lab Disposal ® ATORY US <br /> Sam Ty <br />o fractions <br /> <br /> <br />v