2010-12-13_HYDROLOGY - M1977300 ‎(2)‎

• Permit No: M1977300
• IBM Index Class Name: HYDROLOGY
• Doc Date: 12/13/2010
• Doc Name: October 2010 Surface Water Monitoring Data- Part 2
• From: Cotter
• To: CDPHE-WQCD
• Permit Index Doc Type: Hydrology Report
• Email Name: DB2
• Media Type: D
• Archive: No

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Chain of Custody and Analytical Request Record
PLEASE PRINT; provide as much information as possible. Refer to corresponding notes on reverse side. Page 1 of 1
Company Name: Cotter Corporation Project Name: Schwartrwaider Water Monitoring Program -
Tracking No. 3692013 00179827 DATE: _10/28/10 SSTF: S 25377---S25383
Report Mail Address:
Cotter Corporation - Canon City Mill Sampler Name if other than Contact:
PO Box 1750; Canon City, CO 81215-1750 Voice: ? Name: K ? 9-?75i 7413 ext. 213 1-303-642-3893 mine phone
Invoice Address: Bob Tennant 1-7 9-371-3009-cell
Invoice Contact: Kristy Usnick Purchase Order ELI Quote A
PO Box 1750 Tel: [phone] ext. 213
Canon City, CO 81215-1750 Fax: [phone]
ify ELI prior to
Report Required For: POTWMlWTP 0 T?a?d
Recei Tem
Other SK sample P
W mittal for ?;' 4?
Special Report Formats - ELI must be noted .. ???
prior to sample submittal for the following: w m itional char
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NELAC ? A2LA ? Leve1 1V ? ~ schedulin
eal
3 m Q Comments: Custody
Other Y
EDD/EDT ? Format E a c o S&A Schedule Code : Intact
SAMPLE I SW CODE 1,3 YIN
x Table 1 Signature
IDENTIFICATION Collection Collection z Frequency 1,2,3,4 Y / N
(Name, Location, Date Time
Match LAB ID
Interval etc MATRIX > > N Y / N
' SW F13RG 10/27/18 14:40 Water ? ? ? ® ? ? ? ? ? ? ® ? Tablel
2 SW ARH 10/28/10 9:15 Water ? ® ® ? ? ? ? ? ? ? ® ? Code 3
3 SW LLHG 10/28110 10:45 Water ? ® ® ? ? ? ? ? ? ? ® ? Code 3
4
? ? ? ? ? ? ? ? ? ? ? ?
s SW OS 10/27/10 11:35 Water ® ? ? 13 ? ? ? ? ? 13 ® ? Code 1
a SW BOS 10/27/10 11:45 Water 013111 11 ? ? ? ? ? ? ® ? Code 1
SW GS 10/27/10 11:50 Water ® ? ? ? ? ? ? ? ? ? ® ? Code l
a SW BPL 10/27/10 12:00 Water ® ? ? ? ? ? ? ? ? ? ® ? Code 1
? ? ? ? ? ? ? ? ? ? ? ?
10 ? ? ? ? ? ? ? ? ? ? ? ?
Custod Relinquished by: Bob Tennant Date/Time:10/28/10
Y 12:30 Shipped by: Received b
Record by Date/Time:
MUST be Relinquished by' Date/Time: TT---Ls- /J Shipped by:
V Receive ate/Time. 2y yc
Signed Sample Disposal: Return to Client ? Lab Disposal ® LABORATORY USE ONLY
Sample T yp# of fractions